Quantitative analysis of bacteria in forefoot surgery: a comparison of skin preparation techniques

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

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

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 Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

Randomized Trial of Dilute Povidone-Iodine Soak and Scrub for Orthopaedic Foot and Ankle Surgery

BACKGROUND

There is no consensus as to which skin antiseptic solution is most effective at reducing infection following orthopaedic foot and ankle surgery. The purpose of this study is to determine if the addition of a dilute povidone-iodine soak and scrub to a standard preparation with alcohol and chlorhexidine decreases positive bacterial culture rates from the hallux nailfold.

METHODS

In this prospective, randomized controlled trial, 242 subjects undergoing orthopaedic foot and ankle surgery were randomized to one of 2 groups. The control group received our standard 2-step skin antiseptic preparation of an alcohol scrub (step 1) followed by chlorhexidine/alcohol paint (step 2). The intervention group received a 3-minute dilute povidone-iodine soak and scrub followed by that same standard 2-step skin preparation. Immediately before skin incision, culture swabs were taken from the hallux nailfold of both groups.

RESULTS

Of the 257 subjects enrolled and randomized, 242 (94.2%) completed the study, satisfying the a priori sample size requirement of 242 subjects. There were no crossovers between groups. There were no differences in baseline characteristics between groups (P > .05 for each). There was no difference in bacterial growth rates between groups (26.8% growth in the intervention group vs 26.9% growth in the control group, P = .991).

CONCLUSION

The hallux nailfold is one of the most difficult to sterilize areas prior to orthopaedic foot and ankle surgery. This randomized controlled trail found no benefit to adding a 3-minute dilute povidone-iodine soak and scrub to a standard skin preparation with alcohol and chlorohexidine.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery

Preoperative skin preparation is an effective method to prevent surgical site infections (SSI). Alcoholic chlorhexidine (CHG) and povidone iodine (PV-I) are the most widely used antiseptic agents. This meta-analysis aims to determine their efficacy in reducing natural bacterial skin flora in clean orthopedic surgery. A systematic search was conducted through current literature up to June 2021 to identify clinical randomized trials that compared the efficacy of alcoholic chlorhexidine and povidone iodine in reducing bacterial skin colonization after preoperative skin preparation. A meta-analysis was conducted. Of 235 screened articles, 8 randomized controlled trials were included. The results of the meta-analysis demonstrate a significantly lower positive culture rate in the chlorhexidine group than in the povidone iodine group (RR = 0.53, 95% Cl: 0.32-0.88). The present data show the superiority of chlorhexidine in reducing the normal bacterial flora compared to povidone iodine in clean orthopedic surgery.

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.

Skin Preparation Techniques for Orthopedic Foot and Ankle Surgery: A Current Concepts Review

Surgical site infection (SSI) following orthopedic foot and ankle surgery is associated with morbidity, mortality, and cost to the healthcare system. The local anatomy and physiology predispose patients undergoing procedures to elevated risk. In particular, sterilizing of the webspaces, nailfolds, and subungual areas presents challenges, and the preferred skin antisepsis technique for foot and ankle procedures has not yet been defined. Skin antiseptic solutions (SASs) consist of 3 main categories: alcohol, chlorhexidine, and iodine-based solutions. This review of the literature supports a combined chlorhexidine and alcohol preparation technique; however, there are a number of studies that suggest otherwise. In addition, there is variable evidence for the use of alternatives to the standard soft sponge application technique, including immersion, bristled brush, and cotton gauze application. These alternatives may have a particular advantage in the forefoot. Most studies to date use growth from skin swab cultures after skin preparation as the primary outcome. Higher-level studies with large subject populations and more meaningful clinical outcomes will be required to solidify guidelines for preoperative skin antisepsis prior to foot and ankle procedures.Level of Evidence: Level V, expert opinion.

Comparing Surgeon Adherence with World Health Organization Antiseptic Guidelines for Surgical Site Preparation in the United Kingdom and India

Background: Skin preparation with an antiseptic solution aims to reduce surgical site infection rates. Surgical site infections (SSIs) create a high burden on healthcare systems with impacts on morbidity, mortality, and cost. In 2016, The World Health Organization (WHO) conducted an extensive systematic review and meta-analysis of the existing evidence. From this, they recommended the use of "alcohol based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures." This study aimed to assess surgeon compliance with this guidance in the United Kingdom and India. Methods: A multiple-choice questionnaire was developed to assess surgeon preferences for antiseptic use in their surgical site preparation. The end point of data collection was defined after 50 responses in each region. Results: The majority of respondents in each center was general surgeons (n = 24, 48% United Kingdom; n = 21, 45% India), and registrars (n = 22, 44% United Kingdom; n = 23, 49% India). No surgeon preferred the use of any aqueous preparation. Chlorhexidine gluconate (CHG) was the preparation used most commonly in both centers (n = 30, 64% India; n = 24, 48% United Kingdom). In India, this represented a statistically significant difference (p = 0.0008), however, this was not observed in the United Kingdom (p = 0.22). There were no statistically significant differences between surgeon's reasons between the United Kingdom and India, other than "easier to see" (p = 0.016). Conclusions: This data show a reduced compliance of U.K. surgeons with WHO guidance for antiseptic use compared with Indian surgeons. Although the WHO has attempted to summarize the existing data to minimize the previous uncertainty surrounding antiseptic choices, the use of CHG continues to not be adopted widely. To draw robust conclusions to provide the foundations of further guidelines, future research should focus on prospective randomized controlled trials with large numbers across multiple surgical specialties.

Chlorhexidine-alcohol versus iodine-alcohol for surgical site skin preparation in an elective arthroplasty (ACAISA) study: a cluster randomized controlled trial

OBJECTIVES

Surgical site skin preparation is an effective method to prevent wound complications. The optimal agent has not been established, and guidelines contain conflicting recommendations.

METHODS

The aim of alcoholic chlorhexidine or alcoholic iodine skin antisepsis (ACAISA) was to assess the efficacy of surgical site skin preparation with 0.5% chlorhexidine gluconate (w/v) in 70% ethanol (v/v) to 1% iodine (w/v) in 70% ethanol (v/v). This was a cluster randomized, controlled, single-centre, assessor-blinded, superiority trial in patients undergoing elective hip or knee arthroplasty. Each surgeon had a set operating day and the unit of randomization was the day of surgery. The primary outcome was superficial wound complication, defined as a composite endpoint of superficial incisional surgical site infection and/or clinically significant wound ooze in the 30 days following arthroplasty. The secondary outcome was any surgical site infection, including prosthetic joint infection. Outcome ascertainment was undertaken by an independent verification panel. The primary analysis was intention-to-treat, performed at the individual level. Taking into account the clustering effect, analysis of primary and secondary outcomes was undertaken at the level of the surgeon.

RESULTS

A total of 780 participants were included; 390 participants were allocated chlorhexidine-alcohol and 390 participants were allocated iodine-alcohol. There was no difference in superficial wound complications: 19 (4.9%) versus 15 (3.8%) respectively (OR 1.28; 95%CI 0.62, 2.63; p 0.50). There was an increased odds of surgical site infection in the chlorhexidine-alcohol group compared to iodine-alcohol: 12 (3.1%) versus four (1.0%) respectively (OR 3.06; 95%CI 1.26, 7.46; p 0.014). The odds of prosthetic joint infection were also increased in the chlorhexidine-alcohol arm compared with iodine-alcohol: seven (1.8%) versus two (0.5%) respectively (OR 3.55; 95%CI 1.20, 10.44; p 0.022).

CONCLUSIONS

No difference was observed in the primary outcome of superficial wound complications when chlorhexidine-alcohol and iodine-alcohol were compared. However, on a secondary analysis, iodine-alcohol had greater efficacy than chlorhexidine-alcohol for preventing surgical site infection.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614000177651.

Chlorhexidine 0.5%/70% Alcohol and Iodine 1%/70% Alcohol Both Reduce Bacterial Load in Clean Foot Surgery: A Randomized, Controlled Trial

No consensus exists regarding which cleansing technique, solution, and concentration should be used in orthopedic surgery. The aim of this randomized, controlled trial was to compare the effect of chlorhexidine 0.5%/70% alcohol with iodine 1%/70% alcohol on lowering positive cultures before elective foot surgery and to study any wound complications, infections and allergic reactions. Consecutive patients ≥18 years of age scheduled for a hallux valgus correction or arthrodesis of the first metatarsophalangeal joint were included. Swabs were taken from 2 sites before and twice after preparing the skin and were quantitatively and qualitatively analyzed. The study group consisted of 49 patients with a mean age of 52.3 ± 14.4 (range 22 to 75) years of whom 42 (86%) were female. No significant differences were observed for positive cultures between the chlorhexidine (73%, 2%, and 12%) and iodine (68%, 7%, and 9%) group at any time point. Coagulase-negative staphylococci were the most commonly isolated micro-organisms found after skin preparation. Occasionally, Bacillus spp and Corynebacterium spp were cultured. The complication rate 2 weeks postoperatively was 0% in the chlorhexidine group versus 8.7% (n = 2) in the iodine group (delayed wound healing; p = .215). The complication rate at 6 weeks postoperatively was, respectively, 3.8% (n = 1) versus 4.3% (n = 1; both showed swelling and redness; p > .999). There was no significant difference in postoperative wound problems or infection rates between the 2 skin preparation solutions. Chlorhexidine 0.5%/70% alcohol and iodine 1%/70% alcohol both decreased the amount of positive cultures in elective foot surgery.

Skin antisepsis with chlorhexidine versus iodine for the prevention of surgical site infection: A systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is one of the most frequent health care-associated infections. One of the practices to reduce their incidence is preoperative skin antisepsis. Two of the most commonly active components used are chlorhexidine gluconate and povidone iodine. Of 3 reviews conducted between 2010 and 2012 comparing antiseptics, 2 were in favor of chlorhexidine; however, the latest was unable to draw conclusions.

PURPOSE

To verify whether recent evidence supports the hypothesis that chlorhexidine in preoperative antisepsis is more efficient than other antiseptics in reducing SSI rates.

PROCEDURES

We conducted a systematic review from 2000-2014 in all languages. The primary end point was SSI incidence and secondary skin bacterial colonization.

RESULTS

Nineteen studies were included. Meta-analysis were conducted for comparable studies for both outcomes. The results of the meta-analysis, including all of the studies in which chlorhexidine was compared with iodophor, were in favor of chlorhexidine for both SSI incidence (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.52-0.92) and bacterial skin colonization (RR, 0.45; 95% CI, 0.36-0.55).

CONCLUSIONS

There is moderate-quality evidence supporting the use of chlorhexidine for preoperative skin antisepsis and high-quality evidence that the use of chlorhexidine is associated with fewer positive skin cultures. Further rigorous trials will be welcomed to attain stronger evidence as to the best antiseptic to be used before surgery.

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.

Wound Hygiene Practices After Total Knee Arthroplasty: Does It Matter?

BACKGROUND

Current literature is limited with regard to standardized postoperative surgical site hygiene after total knee arthroplasty (TKA). With little guidance from the literature, the timing of permissible postoperative cleaning is a decision made by the individual surgeon using anecdotal evidence. A standardized wound care regimen is of particular interest to minimize the risk of infection.

METHODS

To examine what species of bacteria recolonize the surgical site postoperatively, a randomized controlled trial was performed of 16 TKA patients who were allowed to shower at 2 days postoperatively and of 16 patients who were asked to wait until 2 weeks postoperatively before showering after TKA. Culture swabs of skin adjacent to the incision were performed preoperatively, just after incision closure, at dressing removal, and at 2 weeks postoperatively. Bacteria were speciated and compared between groups. A swab of the contralateral knee was performed at 2 weeks as a control. A survey of patient's preference regarding early and late showering was also carried out.

RESULTS

No difference was found between the groups in rate of colonization or bacterial type, and no patients developed infection. Patients overwhelmingly preferred early showering rather than late (P = .28-.99).

CONCLUSION

There is no difference in surgical site bacterial recolonization between early and delayed showering after primary TKA.

Randomised comparison of two skin preparation methods in foot and ankle surgery

BACKGROUND

Foot and ankle surgery has an increased incidence of post-operative surgical site infections. The aim of this study was to examine the efficacy and efficiency of an alternative method of surgical site preparation for foot and ankle surgery.

METHOD

Fifty-one volunteers were recruited for this study which compared standard gauze painting using 2% chlorhexidine with 70% alcohol to immersion of the foot and ankle in a non-sterile bag filled with 60mL of the same solution and rubbing all skin surfaces (bag immersion method). Each method was applied to different feet of each volunteer in a randomised order. Commercially available impression agar slides were used to measure bacteria colony-forming-unit (CFU) counts from four areas of each foot after allowing the preparation to dry. Outcomes included CFU count and preparation time.

RESULT

There was no difference between the methods in terms of CFU count (0 total CFU vs. 1). Preparation time was significantly shorter for the bag immersion method (63.98s vs. 67.98s). Two-side 90% confidence intervals (2.03-6.00) for the difference in means of preparation time demonstrated equivalence using a margin of ±20%.

CONCLUSIONS

The bag immersion method is a valid alternative, equivalent in preparation timing and the elimination of transient skin flora when using 2% Chlorhexidine with 70% alcohol.

A clinical perspective on musculoskeletal infection treatment strategies and challenges

Orthopaedic implants improve the quality of life of patients, but the risk of postoperative surgical site infection poses formidable challenges for clinicians. Future directions need to focus on prevention and treatment of infections associated with common arthroplasty procedures, such as the hip, knee, and shoulder, and nonarthroplasty procedures, including trauma, foot and ankle, and spine. Novel prevention methods, such as nanotechnology and the introduction of antibiotic-coated implants, may aid in the prevention and early treatment of periprosthetic joint infections with goals of improved eradication rates and maintaining patient mobility and satisfaction.

Efficacy of preparation solutions and cleansing techniques on contamination of the skin in foot and ankle surgery

We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001).

Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S& P) followed by alcohol showed significantly better efficacy over PI (S& P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S& P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.

Cite this article: Bone Joint J 2013;95-B:498–503.

The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis

Background

Skin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence.

Methods

We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution.

Results

In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines.

Conclusions

Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.

Postoperative infection after excisional toenail matrixectomy: a retrospective clinical audit

BACKGROUND

Excisional toenail matrixectomies are performed on the area of the foot that has been reported to have the highest concentration of resident microorganisms. A retrospective infection audit was performed to identify whether this unique area of the foot was more susceptible to postoperative infection.

METHODS

A retrospective audit reviewing the postoperative infection rate over a 6-year period after excisional nail matrixectomy in 111 patients was undertaken.

RESULTS

The postoperative infection rate was found to be high (18.9%) relative to that of clean orthopedic foot and ankle surgery (0.5%-6.5%).

CONCLUSIONS

The unique concentration of resident microbes found in the nail folds could help explain the high rate of postoperative infections identified in this study. This may provide some argument to classify excisional nail matrixectomy as clean-contaminated surgery and, thus, warrant routine antibiotic prophylaxis. Further research is recommended to confirm the results of this study and to determine whether appropriately timed oral antibiotic prophylaxis will reduce the infection rate after nail surgery.

Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone–iodine in clean-contaminated surgery

Background

Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone–iodine) for preoperative skin cleansing is unclear.

Methods

A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone–iodine reduced surgical-site infection in clean-contaminated surgery.

Results

The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone–iodine (pooled odds ratio 0·68, 95 per cent confidence interval 0·50 to 0·94; P = 0·019).

Conclusion

Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.