REVIEW ARTICLE
Role of Antiseptics in the Prevention of Surgical Site Infections Kathryn Echols, MD,* Michael Graves, MD,† Keith G. LeBlanc, MD,‡ Sean Marzolf, MD,* and Avis Yount, MD†
BACKGROUND Antiseptics are chemical agents used to reduce the microbial population on the surface of the skin and are used in nearly every surgical procedure today. Despite this, there are currently no definitive guidelines on surgical preoperative antisepsis that indicate a specific regimen based on demonstration of superior efficacy. OBJECTIVE This review serves to examine preoperative antisepsis, including cutaneous bacteriology, preoperative hair removal, preoperative decolonization, surgical attire, and the antiseptic agents themselves. MATERIALS AND METHODS
A review of the literature on surgical antiseptics was performed.
RESULTS Although numerous studies have demonstrated differences in bacterial colonization rates, few well-controlled investigations have demonstrated superiority of a given regimen. The alcohol-based iodophor and chlorhexidine products seem to exhibit greater efficacy than their aqueous counterparts. CONCLUSION More randomized controlled trials will be needed to determine if any specific regimen is most effective. At this point in time, product usage should be based on specific attributes relating to the products, such as iodophors around the eyes and/or ears to avoid irritation and aqueous-based solutions in hair bearing areas because of concern for flammability. Ultimately, it is up to the individual surgeon to tailor the optimal antiseptic regimen for their specific scope of practice. The authors have indicated no significant interest with commercial supporters.
T
he use of antiseptics dates back to the 1840s when Ignaz Semmelweis documented a dramatic reduction in puerperal sepsis associated with the use of appropriate handwashing techniques.1 Antiseptics gained further acclaim when Lister’s use of carbolic acid in the 1870s demonstrated improved infection control and reduction in surgical morbidity.1,2 Since that time, antiseptics have remained an important component of reducing surgical site infections (SSIs), which are defined as any infection occurring at the surgical site within 30 days of the procedure. Despite their importance, there are currently no definitive guidelines on preoperative antiseptic use based on a demonstration of superior
efficacy by any particular agent or regimen.3,4 Preoperative antisepsis involves both scrubbing to remove cutaneous flora physically and chemical killing to minimize the load of resident flora. Clean surgical procedures, defined as those performed after surgical scrubbing with complete sterile technique, have an infection rate of 1% to 4%. Clean– contaminated surgery, in which minor breaks in sterile technique can occur, has an infection rate of 5% to 10%.5 Wounds in office-based cutaneous surgery can be classified as clean or clean–contaminated wounds depending on the procedure type, with infection rates
*Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina; †Section of Dermatology, Department of Medicine, Medical College of Georgia, Georgia Regents University, Augusta, Georgia; ‡Total Skin and Beauty Dermatology, Birmingham, Alabama © 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-0512 Dermatol Surg 2015;41:667–676 DOI: 10.1097/DSS.0000000000000375
·
·
667
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
ranging from 0.07% to 4.25%.5–8 Recent studies have found similarly low infection rates even without the use of prophylactic antibiotics.9 Additionally, guidelines recommend against the use of topical antimicrobial agents for wound healing by primary intention.10–12 A variety of antiseptics were routinely used in these aforementioned studies. The Surgical Site Bacteriology of the Skin Cutaneous flora includes both resident and transient bacteria. Resident bacteria are located primarily in the superficial epidermal layers. A minority (10%–20%) of resident cutaneous floras are in the deeper layers, particularly the pilosebaceous unit, making them more difficult to eradicate with antiseptic agents.13,14 The majority of these bacteria tend to be nonpathogenic and can prevent colonization of the skin with pathogenic bacteria.15 Resident cutaneous floras are found more commonly in creases and folds, particularly in the intertriginous areas.15 Transient floras are temporary inhabitants acquired by contact that are unable to colonize the skin. They are present superficially, loosely attached, and can be easily removed with scrubbing.4,15 Transient floras are the cause of the majority of postoperative wound infections.16 Both the resident and transient floras are influenced by host factors including sex, age, personal health, nutritional status, and location.17 Staphylococcus aureus is the bacteria most commonly implicated in SSIs. This bacteria usually starts as transient flora and transitions to resident flora with sustained inoculation.15 Increasing incidence of antimicrobial resistance of S. aureus has raised concern for treatment-resistant infections.18 Other common bacteria in SSIs include coagulase-negative Staphylococcus, Enterococcus, Escherichia coli, group A streptococci, and Pseudomonas aeruginosa.4,13,16,19 Hair Removal The 1999 Centers for Disease Control and Prevention (CDC) guidelines strongly discourage hair removal before surgery unless it will interfere with the procedure.
668
If removal is deemed necessary, the recommendation is that the hair be clipped immediately before the operation, preferably at a level just above the cutaneous surface with minimal, if any, contact with the skin during clipping.3,20 Preoperative shaving has been linked with an increased risk of SSIs. These are thought to be secondary to microabrasions on the cutaneous surface that facilitate postoperative bacterial growth and subsequent infection.13,21 A recent Cochrane review supported the existing CDC guidelines but acknowledged that most of the clinical trials investigating this subject are underpowered and more research is needed.22 Preoperative Decolonization The 1999 CDC guidelines strongly recommend preoperative antiseptic showering, with the use of products containing chlorhexidine gluconate (CHG) to reduce cutaneous bacterial colonization.3 Antiseptic body washes have been studied in a variety of formulations, including 4% CHG wash, 2% CHG impregnated cloths, alcohol-based products, and 10% povidone–iodine (PVP-I) scrub.19,23–27 Numerous studies have demonstrated significantly decreased bacterial colonization rates using these preoperative body washes.23,27–29 However, recent reviews have been unable to show definitive evidence that preoperative showering reduces SSI.30–32 There is increasing evidence that in patients with known carriage of S. aureus, preoperative decolonization may reduce the rate of SSI. It has been shown that nasal carriage of S. aureus is an independent risk factor for the development of SSI in multiple surgical settings, including dermatologic surgery.33–37 Investigations from various surgical disciplines have shown a reduction in SSI to a rate comparable with noncarriers with the use of protocols to identify and decolonize carriers of S. aureus before surgery.38–41 It remains to be seen if these interventions are beneficial in a dermatologic surgery setting, but a recent prospective randomized study demonstrated a significant reduction in SSI after Mohs surgery among nasal S. aureus carriers with the use of a topical decolonization regimen.37 A variety of decolonization protocols have been described, usually consisting of topical agents used
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
alone or in combination with oral antibiotics.38,39,41,42 Topical decolonization regimens commonly use a combination of CHG body wash once daily plus intranasal mupirocin ointment twice daily for 5 days before surgery. Cherian and colleagues42 recently reported an unblinded randomized controlled trial, which showed that topical decolonization was superior to prophylactic oral antibiotics at reducing the rate of SSI in 693 patients undergoing Mohs surgery who demonstrated nasal carriage of S. aureus. These results suggest that patients with known S. aureus carriage should be considered for topical decolonization before dermatologic surgical procedures, but more research is needed to confirm the validity of these findings. Surgical Attire Centers for Disease Control and Prevention guidelines state that shoe covers should not be worn for the prevention of SSI, which is supported by a 2003 literature review, which failed to find support for use of shoe covers to prevent SSI.12,43,44 The use of sterile gloves (SG) versus nonsterile gloves (NSG) in Mohs micrographic surgery (MMS) is still a matter of debate. Although studies have demonstrated a statistically significant difference in bacterial load favoring use of SG, the clinical significance of this finding is uncertain.45 A large prospective cohort study of MMS cases demonstrated an absolute risk reduction of 20.47% with the use of SG, but this small risk reduction may not correlate with clinical significance in the setting of overall low infection rates in MMS.46 Furthermore, a more recent study demonstrated that the prevalence of SSI in SG versus NSG was almost identical, and the cost of SG is 3.5 times greater.47 A recent Cochrane review evaluating the use of disposable face masks for preventing SSI in clean surgery identified 3 studies, which demonstrated no statistically significant differences between masked versus unmasked SSI rates; however, because of the small number of trials and limitations of the included studies, it is currently unclear if the use of surgical face masks alters SSI rates.48 Antiseptic Scrubs Adequate surgical antisepsis should remove all transient bacteria from the skin, while minimizing the remaining resident flora residing in the pilosebaceous
units.16 Recommendations have included using a detergent to remove physical debris from the skin, followed by an antiseptic scrub to kill bacteria.15 Scrubbing has been considered to be more important for disinfection than the type of agent used; a 50% reduction in bacteria has been described for every 6 minutes spent scrubbing.15 However, the importance of a full 5-minute scrub in directly preventing SSIs has been challenged and currently is not used by most dermatologic surgeons.49 The ideal antiseptic agent should be capable of killing all bacteria, fungi, viruses, protozoa, and spores present on host skin while remaining nontoxic, hypoallergenic, safe for use in all body regions, and nonabsorbable percutaneously to reduce systemic side effects and toxicity.4 Fast onset of action, continued residual antimicrobial activity, and safety and efficacy with repeated use are also desireable.4 As antiseptics have the risk of bacterial contamination with repeated use from the same receptacle, the ideal agent would be in single-use packets.15 Alcohol Alcohol is effective against Gram-positive and Gramnegative bacteria and many fungi and viruses.4 However, alcohol is not effective against most spores.13 Alcohol has been shown to inactivate HIV in vitro, but this effect was measured after contact times between 2 to 10 minutes.50 Therefore, it should not be relied on for this purpose in normal clinical settings because of its rapid evaporation. Blood and other organic compounds do not affect the antimicrobial action of alcohol.19 Alcohol provides fast acting antisepsis, but its lack of continued antimicrobial effect with drying precludes its stand-alone use.21,51 The utility of alcohol lies in its combination with more persistent antiseptic agents such as iodophors or CHG. These combinations provide more persistent antimicrobial activity that can last for the duration of surgery.21,51 Alcohol also has a role in developing countries where alternative antiseptics may not be available.52 When choosing an alcohol-based regimen, isopropyl alcohol is preferred over ethyl alcohol because of its superior antibacterial spectrum and less volatile nature.13 Alcohol and alcohol-based antiseptics are flammable if the product is still wet on the skin, and there have been
41:6:JUNE 2015
669
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
burns related to fire from electrosurgery after use of alcohol-based antiseptics.53,54 To prevent fires, alcohol should be given adequate time to dry, avoided in hair bearing areas where drying may be impaired, and pooling of the product should be prevented.21,54 Chloroxylenol Chloroxylenol is an antiseptic that is no longer commonly used because of its decreased efficacy in comparison with chlorhexidine and povidone–iodinebased products. One study demonstrated that the number of bacterial colonies after application of chloroxylenol was not statistically significant from the colony count on the skin before antiseptic application.55
heterogeneity in application method exists between studies with a range of time spent scrubbing and variable numbers of applications of PVP-I paint after scrub.4,14,28,49,52,62–69 This regimen of 5-minute scrub followed by painting is not performed by most dermatologic surgeons, as similar efficacy has been observed using the paint-only method.49,66,70 PVP-I should be allowed to dry fully after application for maximal antimicrobial effect.71 Drying time recommendations range from 2 to 20 minutes.67,71,72 A minimum of 2 minutes is recommended because iodophors require approximately 2 minutes of contact time to allow release of free iodine.72 If not removed from the skin, PVP-I can have sustained activity for 1 to 2 hours.15,73 Aqueous-Based Chlorhexidine
Aqueous-Based Iodophors Povidone–iodine (PVP-I), a combination of polyvinylpyrrolidone and iodine, is an iodophor that allows for steady release of iodine in a water-soluble product.2 The bactericidal effect of PVP-I is determined by the concentration of free iodine; a 10% PVP-I formula contains 1% available iodine.2–4 Iodophors are effective against a wide range of microorganisms including Gram-positive and Gramnegative bacteria, some bacterial spores, yeast, other fungal forms, protozoa, and viruses such as HIV, and hepatitis B virus (HBV).2,13,51,56 These are nonirritating to the eyes and mucous membranes, provide visibility to areas covered, and do not readily remove surgical markings.57 However, blood and serum proteins can inactivate PVP-I and prolonged or excessive application can cause systemic toxicity.3,15,51 PVP-I has been documented to cause an iododerma-like reaction and chemical burns.58,59 Anaphylaxis has occurred in patients with a systemic povidone–iodine allergy after topical use; therefore, topical PVP-I is not recommended in those with a history of systemic allergy.59,60 Although impaired wound healing has been demonstrated with direct application of PVP-I into wound beds, this seems not to be significant clinically.2,61 Traditional application involves a 5minute scrub with PVP-I surgical scrub followed by rinsing with sterile gauze saturated with water, then painting of the surgical site with aqueous PVP-I solution as recommended by the manufacturer. However,
670
Chlorhexidine gluconate is a bisbiguanide that is bacteriostatic at low concentrations and bactericidal at higher concentrations.74,75 Chlorhexidine gluconate has efficacy against a wide range of Gram-positive and Gram-negative bacteria, many viruses including HIV and HBV, and some fungi.3,13,56,72,76–78 Higher concentrations correlate with lower bacterial load.79 It provides residual antimicrobial action by binding to the stratum corneum and is resistant to removal by alcohol.13 Manufacturer recommendations for application include a 2-minute swab of the surgical site followed by drying with a sterile towel, then an additional 2-minute application followed by towel drying. However, the actual methods used are heterogeneous and include a 5- to 7-minute CHG scrub alone or scrub followed by painting with CHG– alcohol or isopropyl alcohol solution.62,64–67 One source recommended not wiping the area dry of CHG after application to allow its persistent antibacterial effect.79 Drying is recommended before incision, but actual time to allow for adequate drying is rarely cited. Current recommendations include allowing for at least 2 minutes of contact time before surgical incision.79 Chlorhexidine gluconate produces limited irritation to the skin and can be used on the oral mucosa and is not inactivated by blood or other organic material.72 However, CHG is ototoxic and can cause conjunctival irritation.13 It has been reported to cause
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
damage to the corneal epithelium and even lead to permanent corneal opacification.80 A test of rabbit corneas showed 4% chlorhexidine and 4% isopropyl alcohol with detergent to be toxic to the cornea.81 A study of ototoxicity performed on cats showed that application of chlorhexidine (2% and 0.05%) produced damage to the sensory epithelium resulting in a sensorineural hearing loss.82 This effect of chlorhexidine seems to be related to its concentration, and the clinical severity of injury often progresses over several weeks after exposure.83 It has also been shown to erase surgical site markings significantly more than PVP-I.84 Additionally, anaphylaxis has been demonstrated in response to topical application of CHG.85
Chlorhexidine Alcohols The combination of alcohol and CHG benefits from the potency of the alcohol and the persistent activity of the CHG. The mechanism of antimicrobial action of CHG–alcohol is attributed to the combined mechanisms of each of the products. The most popular agent is ChloraPrep (CareFusion, Inc., El Paso, TX), which contains 2% CHG and 70% isopropyl alcohol (CHG-IA), and has a duration of action of 48 hours.88 Chlorhexidine gluconate-IA should be applied for 30 seconds to dry surgical sites and should be allowed to dry for at least 30 seconds. For moist surgical sites such as the inguinal folds, 2-minute application followed by 1-minute drying time is recommended by the manufacturer; however, variable drying times ranging from 3 to 10 minutes were used in clinical studies.84,87
Alcohol-Based Antiseptics Product Comparisons Povidone–Iodine Alcohols Povidone–iodine–ethanol (PVP-I-ethanol or PI-ethanol) has the mechanism of action of PVP-I combined with that of alcohol. The alcohol allows for rapid acting antisepsis of the product, and the combination of alcohol with PVP-I increases the free iodine concentration higher than with PVP-I alone.51 Current available options include DuraPrep (3M Health Care, St. Paul, MN) and Prevail-FX (Cardinal Health, Dublin, OH). DuraPrep is iodine–povacrylex with 0.7% available iodine and 74% isopropyl alcohol by weight (wt/wt) (PI-IA), whereas Prevail-FX is PVP-I and a polymer complex with 0.83% available iodine dissolved in isopropyl alcohol 72.5% (wt/wt) (PVP-IA). Application of both products involves painting a single uniform coat over the operative site; excess product can be removed with absorbent towels or gauze. Both products form a water-resistant (PVP-IA) or water-insoluble (PI-IA) film on the surface of the skin with drying, which contributes to a duration of action of 48 hours or more.73,86 Recommended drying time is at least 2 to 3 minutes, but a longer 5-minute drying time should be considered when electrosurgery will be used to avoid fires.54 Although the film is resistant to removal by saline, which is thought to increase its antimicrobial efficacy, it can be difficult to remove after surgery is complete and may not be practical for brief procedures.16,87
PVP-I seems to have the broadest spectrum of action with excellent coverage of Gram-positive bacteria and good coverage of Gram-negative bacteria, Mycobacterium tuberculosis, fungi, viruses, and spores. Alcohol and CHG have similar spectrums of action, although alcohol is not sporicidal, and CHG has limited activity against the tubercle bacillus and fungi.72 However, it is not clear if these differing spectrums are clinically significant as the vast majority of wound infections are due to bacteria. The small infection rate in clean surgery makes appropriate powering of studies difficult. One study comparing over 1,800 patients using PVP-I versus normal saline had an infection rate of 0%.89 Smaller studies have shown superiority of aqueous- and alcohol-based CHG over PVP-I in reducing both bacterial colony counts and SSIs.62–65,88,90 A recent multicenter prospective cohort study of 20,821 MMS cases found that preoperative use of chlorhexidine was associated with a lower risk for infection.46 However, a 2009 Cochrane review found insufficient evidence in high-quality studies to recommend one antiseptic over another.4 Recent meta-analyses comparing alcohol- and aqueous-based CHG with aqueous PVP-I show superiority for CHG in preventing SSI in a variety of surgical procedures.66,67 These same results have been seen in a meta-analysis on catheter site
41:6:JUNE 2015
671
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
672
Antiseptic Alcohol
MOA Denatures proteins
Antimicrobial Coverage Gram-positive and Gram-negative bacteria, many fungi, and viruses
Onset
Duration Negatives/Risks Examples
Rapid
Short acting
Not active against bacterial spores Aqueous-based Free iodine oxidizes and iodophors substitutes microbial contents causing protein and DNA damage
Gram-positive and Gram-negative bacteria, yeast, and other fungal forms, protozoa, some viruses (HIV, HBV), and some bacterial spores
Intermediate
Intermediate
Alcohol-based iodophors
Rapid
Alcohol-based CHG
MOA of alcohol combined with that of aqueous CHG
Improved Gram-negative bacterial coverage
Improved Gram-negative bacterial coverage
Isopropyl alcohol
Short duration of action
Ethyl alcohol
Inactivated by blood and serum proteins
$0.03*
Betadine
$0.19*
Hibiclens
$0.31*
DuraPrep
$3.08†
Risk of skin reaction with iodine sensitivity
Aqueous-based Depolarizes bacterial cell walls Gram-positive and Gram-negative CHG and damages the cytoplasmic bacteria, yeasts, some other fungi, membrane, resulting in leakage many viruses, and prevents of cytoplasmic contents outgrowth but not germination of bacterial spores
MOA of alcohol combined with that of aqueous iodophors
1–2 h
High flammability risk
Cost per Application
6h
Prolonged or excessive application can cause systemic toxicity Ototoxic Causes conjunctival irritation Decreased visibility of surgical site markings compared with iodophors
Rapid
48 h
48 h
Skin irritation/ sensitivity related to iodine Film can be difficult to remove Risks of alcohol and CHG
Prevail-Fx ChloraPrep
*Pricing based on estimated volume per application of 15 mL. †Pricing based on application of a single 6 mL DuraPrep applicator. ‡Pricing based on application of a single 3 mL ChloraPrep One Step applicator. MOA, mechanism of action.
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
$1.08‡
ANTISEPTICS IN SURGERY
DERMATOLOGIC SURGERY
TABLE 1. Characteristics of Antiseptic Solutions
ECHOLS ET AL
preparation, with less catheter tip positivity and less blood stream infections.91 A recent large study by Darouiche and colleagues63 showed reduction of SSI by 41% with CHG-alcohol compared with aqueous PVPI. However, the perceived efficacy of CHG in skin antisepsis is often based on evidence for the efficacy of CHG-alcohol combination with failure to acknowledge the role of alcohol. A meta-analysis of the role of CHG in skin antisepsis found good evidence favoring CHG-alcohol combinations over aqueous PVP-I, but the superiority was not found to hold against PVP-I plus alcohol or other competitors combined with alcohol.92 In studies comparing PI–alcohol with PVP-I solution alone, there were no statistically significant rates of decreased infection.68,69,93 Chlorhexidine gluconate– alcohol has been shown to be more efficacious than PI– alcohol in decreasing bacterial colony counts after use in concentrations of 0.5%, 2%, and 4%.23,55,62,94 However, a recent large study of general surgery patients comparing PI–alcohol with CHG–alcohol and PVP-I showed a trend toward decreased SSIs in both the PI–alcohol and PVP-I groups when compared with CHG–alcohol.68 Skin irritation potential and product cost must also be taken into account when selecting the appropriate antiseptic. A comparison of 1% CHG–ethanol, 2% CHG–isopropyl alcohol, and 10% PVP-I solution demonstrated a trend of decreased skin irritation potential using 1% CHG–ethanol; larger studies are needed to determine if the difference is significant.95 Regarding cost, an observational study found that PVP-I skin disinfection is associated with systematic adjunctive costs from auxiliary materials and a significantly prolonged drying time compared with CHG leading to increased operating time; these adjunctive costs are considered to be on the same order of magnitude as the disinfectant cost itself.96 These additional costs are an important consideration when making direct per unit product cost comparisons (Table 1).
on demonstration of superior efficacy. Although numerous studies have demonstrated differences in bacterial colonization rates, few well-controlled investigations have demonstrated superiority of a given regimen. The alcohol-based iodophor and CHG products seem to exhibit greater efficacy than their aqueous-based counterparts. More randomized controlled trials will be needed to determine if any specific regimen is most effective. At this point in time, product usage should be based on specific attributes relating to the products, such as iodophors around the eyes and/or ears to avoid irritation and aqueous-based solutions in hair bearing areas because of concern for flammability. Ultimately, it is up to the individual surgeon to tailor the optimal antiseptic regimen for their specific scope of practice.
References 1. Polk HC, Cheadle WG, Franklin GA. Principles of operative surgery. In: Townshend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery: the biological basis of modern surgical practice (16th ed). Philadelphia: W.B. Saunders; 2001; pp. 163–170. 2. Goldenheim PD. An appraisal of povidone-iodine and wound healing. Postgrad Med J 1993;69:97–105. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250–78. 4. Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2004:CD003949. 5. Messingham MJ, Arpey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg 2005;31(8 Pt 2):1068–78. 6. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol 2003;139:143–52. 7. Whitaker DC, Grande DJ, Johnson SS. Wound infection rate in dermatologic surgery. J Dermatol Surg Oncol 1988;14:525–8. 8. Futoryan T, Grande D. Postoperative wound infection rates in dermatologic surgery. Dermatol Surg 1995;21:509–14. 9. Rogers HD, Desciak EB, Marcus RP, Wang S, et al. Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics. J Am Acad Dermatol 2010;63:842–51. 10. Welsh A, editor. Surgical site infection: prevention and treatment of surgical site infection. National Institute for Health and Clinical Excellence, National Collaborating Centre for Women’s and Children’s Health: London, 2008.
Conclusion
11. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia: Canberra ACT, 2010.
Currently, no definitive guidelines on surgical preoperative antisepsis indicate a specific regimen based
12. Merollini KMD, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline
41:6:JUNE 2015
673
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
recommendations and expert opinion. Am J Infect Control 2013;41: 221–6. 13. Sebben JE. Sterile technique and the prevention of wound infection in office surgery—part II. J Dermatol Surg Oncol 1989;15:38–48. 14. Jeng DK, Severin JE. Povidone iodine gel alcohol: a 30-second, onetime application preoperative skin preparation. Am J Infect Control 1998; 26:488–94. 15. Bennett RG. Microbiologic considerations in cutaneous surgery. In: Bennett RG, Fundamentals of cutaneous surgery. St. Louis: Mosby; 1988; pp. 136–78. 16. Ammirati CT. Aseptic technique. In: Robinson JK, Hanke CW, Siegel DM, Fratila A, editors. Surgery of the skin: procedural dermatology (2nd ed). St. Louis, MO: Elsevier, 2010; pp. 29–41. 17. Noparat W, Siripanichakorn K, Tribuddharat C, Danchaivijitr S. Persistence of antimicrobial effect of antiseptics in surgical hand hygiene regimens. J Med Assoc Thai 2005;88:177–82. 18. Klevens RM, Morrison MA, Nadle J, Petit S, et al. Invasive methicillinresistant Staphylococcus aureus infections in the United States. JAMA 2007;298:1763–71. 19. Seal LA, Paul-Cheadle D. A systems approach to preoperative surgical patient skin preparation. Am J Infect Control 2004;32:57–62. 20. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011:CD004122. 21. Segal CG. Infection control: start with skin: preoperative skin preparation systems help reduce surgical site infections. Nurs Manage 2006;37:46–52. 22. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2006: CD004122. 23. Veiga DF, Damasceno CV, Veiga-Filho J, Figueiras RG, et al. Povidone iodine versus chlorhexidine in skin antisepsis before elective plastic surgery procedures: a randomized controlled trial. Plast Reconstr Surg 2008;122:170e–1e. 24. Johnson AJ, Daley JA, Zywiel MG, Delanois RE, et al. Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthroplasty 2010;25:98–102. 25. Zywiel MG, Daley JA, Delanois RE, Naziri Q, et al. Advance preoperative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty. Int Orthop 2011;35:1001–6. 26. Murray MR, Saltzman MD, Gryzlo SM, Terry MA, et al. Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery. J Shoulder Elbow Surg 2011;20:928–33. 27. Veiga DF, Damasceno CV, Veifa-Filho J, Silva RV, et al. Influence of povidone-iodine preoperative showers on skin colonization in elective plastic surgery procedures. Plast Reconstr Surg 2008;121: 115–8.
33. Monge Jodra V, Sainz de Los Terreros Soler L, Diaz-Agero Perez C, Saa Requejo CM, et al. Excess length of stay attributable to surgical site infection following hip replacement: a nested case-control study. Infect Control Hosp Epidemiol 2006;27:1299. 34. Bozic KJ, Kurtz SM, Lau E, Ong K, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 2010;468:45. 35. Kurtz SM, Ong KL, Lau E, Bozic KJ, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468:52. 36. Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery 2003;134:S10–7. 37. Tai YJ, Borchard KLA, Gunson TH, Smith HR, et al. Nasal carriage of Staphylococcus aureus in patients undergoing Mohs micrographic surgery is an important risk factor for post-operative surgical site infection: a prospective randomized study. Australas J Dermatol 2013; 54:109–14. 38. Kim DH, Spencer M, Davidson SM, Li L, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 2010;92:1820–6. 39. Roa N, Cannella B, Crossett LS, Yates AJ Jr, et al. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 2011;26:1501–7. 40. Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871–7. 41. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, et al. Preventing surgical site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:9–17. 42. Cherian P, Gunson T, Borchard K, Tai Y, et al. Oral antibiotics versus topical decolonization to prevent surgical site infection after Mohs micrographic surgery—a randomized, controlled trial. Dermatol Surg 2013;39:1486–93. 43. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology, and prevention. J Hosp Infect 2008;70:3–10. 44. Santos AM, Lacerda RA, Graziano KU. Evidence of control and prevention of surgical site infection by shoe covers and private shoes: a systematic literature review. Rev Lat Am Enfermagem 2005;13: 86–92. 45. Creamer J, Davis K, Rice W. Sterile gloves: do they make a difference? Am J Surg 2012;204:976–9.
28. Magera JS, Inman BA, Elliott DS. Does preoperative topical antimicrobial scrub reduce positive surgical site culture rates in men undergoing artificial urinary sphincter placement? J Urol 2007;178: 1328–32.
46. Alam M, Ibrahim O, Nodzenski M, Strasswimmer JM, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol 2013;149:1378–85.
29. Edmiston CE, Okoli O, Graham MB, Sinski S, et al. Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. AORN J 2010;92:509–18.
47. Mehta D, Chambers N, Adams B, Gloster H. Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery. Dermatol Surg 2014;40:234–9.
30. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2012;9:CD004985. 31. Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, et al. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2012; 33:608–17.
674
32. Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control 2013;41:167–73.
48. Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev 2014;2:CD002929. 49. Ellenhorn JD, Smith DD, Schwarz RE, Kawachi MH, et al. Paint-only is equivalent to scrub-and-paint in preoperative preparation of abdominal surgery sites. J Am Coll Surg 2005;201:737–41.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
50. Van Bueren J, Larkin DP, Simpson RA. Inactivation of human immunodeficiency virus type 1 by alcohols. J Hosp Infect 1994;28: 137–48. 51. Nishimura C. Comparison of the antimicrobial efficacy of povidoneiodine, povidone-iodine-ethanol and chlorhexidine gluconate-ethanol surgical scrubs. Dermatology 2006;212:21–5.
71. Workman ML. Comparison of blot-drying versus air-drying of povidone-iodine-cleansed skin. Appl Nurs Res 1995;8:15–7. 72. Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control 1988;16:253–66. 73. Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol 2009;11:190–5.
52. Meier DE, Nkor SK, Aasa D, OlaOlorun DA, et al. Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country. World J Surg 2001;25:441–3.
74. Russell AD. Chlorhexidine: antimicrobial action and bacterial resistance. Infection 1986;14:212–5.
53. Weber SM, Hargunani CA, Wax MK. DuraPrep and the risk of fire during tracheostomy. Head Neck 2006;28:649–52.
75. Denton GW. Chlorhexidine. In: Block SS, ed. Disinfection, sterilization, and preservation (5th ed). Philadelphia: Lippincott Williams & Wilkins; 2001; pp. 321–336.
54. Tooher R, Maddern GJ, Simpson J. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004;74:382–5. 55. Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am 2005;87: 980–5. 56. Kawana R, Kitamura T, Nakagomi O, Matsumoto I, et al. Inactivation of human viruses by povidone-iodine in comparison with other antiseptics. Dermatology 1997(Suppl 2):29–35. 57. Keser A, Bozkurt M, Taner OF, Yorgancigil B, et al. Evaluation of antiseptic use in plastic and hand surgery. Ann Plast Surg 2005;55:490–4. 58. Masse M, Falanga V, Zhou LH. Use of topical povidone-iodine resulting in an iododerma-like eruption. J Dermatol 2008;35:744–7.
76. Modak S, Sampath L, Miller HSS, Millman I. Rapid inactivation of infectious pathogens by chlorhexidine-coated gloves. Infect Control Hosp Epidemiol 1992;13:463–71. 77. Montefiori DC, Robinson WE Jr, Modliszewski A, Mitchell WM. Effective inactivation of human immunodeficiency virus with chlorhexidine antiseptics containing detergents and alcohol. J Hosp Infect 1990;15:279–82. 78. Wood A, Payne D. The action of three antiseptics/disinfectants against enveloped and non-enveloped viruses. J Hosp Infect 1998;38:283–95. 79. Stinner DJ, Krueger CA, Wenke MJC. Time-dependent effect of chlorhexidine surgical prep. J Hosp Infect 2011;79:313–6.
59. Nahlieli O, Baruchin AM, Levi D, Shapira Y, et al. Povidone-iodine related burns. Burns 2001;27:185–8.
80. Phinney RB, Mondino BJ, Hofbauer JD, Meisler DM, et al. Corneal edema related to accidental Hibiclens exposure. Am J Ophthalmol 1988;106:210.
60. Le Pabic F, Sainte-Laudy J, Blanchard N, Moneret-Vautrin DA. First case of anaphylaxis to iodinated povidone. Allergy 2003;58:826–7.
81. Mac Rae SM, Brown B, Edelhauser HF. The corneal toxicity of presurgical skin antiseptics. Am J Ophthalmol 1984;97:221–32.
61. Kramer SA. Effect of povidone-iodine on wound healing: a review. J Vasc Nurs 1999;17:17–23.
82. Igarashi Y, Suzuki J. Cochlear ototoxicity of chlorhexidine gluconate in cats. Arch Otorhinolaryngol 1985;242:167–76.
62. Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine provides superior skin decontamination in foot and ankle surgery. Clin Orthop Relat Res 2005;438:204–8.
83. Willoughby K. Chlorhexidine and ototoxicity in cats. Vet Rec 1989; 124:547.
63. Darouiche RO, Wall MJ, Itani KF, Otterson MF, et al. Chlorhexidinealcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18–26. 64. Paocharoen V, Mingmalairak C, Apisarnthanarak A. Comparison of surgical wound infection after preoperative skin preparation with 4% chlorhexidine and povidone iodine: a prospective randomized trial. J Med Assoc Thai 2009;92:898–902. 65. Levin I, Amer-Alshiek J, Avni A, Lessing JB, et al. Chlorhexidine and alcohol versus povidone-iodine for antisepsis in gynecological surgery. J Womens Health 2011;20:321–4. 66. Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic review and meta-analysis of pre-operative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 2010;97: 1614–20. 67. Lee I, Agarwal RK, Lee BY, Fishman NO, et al. Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection. Infect Control Hosp Epidemiol 2010;31:1219–29. 68. Swenson BR, Hedrick TL, Metzger R, Bonatti H, et al. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol 2009;30:964–71.
84. Thakkar SC, Mears SC. Visibility of surgical site marking: a prospective randomized trial of two skin preparation solutions. J Bone Joint Surg 2012;94:97–102. 85. Okano M, Nomura M, Hata S, Okada N, et al. Anaphylactic symptoms due to chlorhexidine gluconate. Arch Dermatol 1989;125: 50–2. 86. Jeng DK. A new, water-resistant, film-forming, 30-second, one-step application iodophor preoperative skin preparation. Am J Infect Control 2001;29:370–6. 87. Stahl JB, Morse D, Parks PJ. Resistance of antimicrobial skin preparations to saline rinse using a seeded bacteria model. Am J Infect Control 2007;35:367–73. 88. Hibbard JS. Analysis comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs 2005;28:194–207. 89. Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study. Plast Reconstr Surg 2005;116:529–31. 90. Culligan PJ, Kubik K, Murphy M, Blackwell L, et al. A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet Gynecol 2005; 192:422–5.
69. Segal CG, Anderson JJ. Preoperative skin preparation of cardiac patients. AORN J 2002;76:821–8.
91. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002;136:792–801.
70. Zdeblick TA, Lederman MM, Jacobs MR, Marcus RE. Preoperative use of povidone-iodine. A prospective, randomized study. Clin Orthop Relat Res 1986;213:211–5.
92. Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012;7:e44277.
41:6:JUNE 2015
675
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
93. Birnbach DJ, Meadows W, Stein DJ, Murray O, et al. Comparison of povidone iodine and Duraprep, an iodophor-in-isopropyl alcohol solution, for skin disinfection prior to epidural catheter insertion in parturients. Anesthesiology 2003;98:164–9. 94. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, et al. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am 2009;91:1949–53. 95. Nishihara Y, Kajiura T, Yokota K, Kobayashi H. Evaluation with a focus on both the antimicrobial efficacy and cumulative skin irritation potential of chlorhexidine gluconate alcohol-containing preoperative skin preparations. Am J Infect Control 2012;40:973–8.
676
96. Magalini S, Pepe G, Panunzi S, De Gaetano A, et al. Observational study on preoperative surgical field disinfection: povidone-iodine and chlorhexidine-alcohol. Eur Rev Med Pharmacol Sci 2013;17: 3367–75.
Address correspondence and reprint requests to: Kathryn Echols, MD, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 578, Charleston, SC 29425, or e-mail: ksfl[email protected]
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright of Dermatologic Surgery is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Role of Antiseptics in the Prevention of Surgical Site Infections Kathryn Echols, MD,* Michael Graves, MD,† Keith G. LeBlanc, MD,‡ Sean Marzolf, MD,* and Avis Yount, MD†
BACKGROUND Antiseptics are chemical agents used to reduce the microbial population on the surface of the skin and are used in nearly every surgical procedure today. Despite this, there are currently no definitive guidelines on surgical preoperative antisepsis that indicate a specific regimen based on demonstration of superior efficacy. OBJECTIVE This review serves to examine preoperative antisepsis, including cutaneous bacteriology, preoperative hair removal, preoperative decolonization, surgical attire, and the antiseptic agents themselves. MATERIALS AND METHODS
A review of the literature on surgical antiseptics was performed.
RESULTS Although numerous studies have demonstrated differences in bacterial colonization rates, few well-controlled investigations have demonstrated superiority of a given regimen. The alcohol-based iodophor and chlorhexidine products seem to exhibit greater efficacy than their aqueous counterparts. CONCLUSION More randomized controlled trials will be needed to determine if any specific regimen is most effective. At this point in time, product usage should be based on specific attributes relating to the products, such as iodophors around the eyes and/or ears to avoid irritation and aqueous-based solutions in hair bearing areas because of concern for flammability. Ultimately, it is up to the individual surgeon to tailor the optimal antiseptic regimen for their specific scope of practice. The authors have indicated no significant interest with commercial supporters.
T
he use of antiseptics dates back to the 1840s when Ignaz Semmelweis documented a dramatic reduction in puerperal sepsis associated with the use of appropriate handwashing techniques.1 Antiseptics gained further acclaim when Lister’s use of carbolic acid in the 1870s demonstrated improved infection control and reduction in surgical morbidity.1,2 Since that time, antiseptics have remained an important component of reducing surgical site infections (SSIs), which are defined as any infection occurring at the surgical site within 30 days of the procedure. Despite their importance, there are currently no definitive guidelines on preoperative antiseptic use based on a demonstration of superior
efficacy by any particular agent or regimen.3,4 Preoperative antisepsis involves both scrubbing to remove cutaneous flora physically and chemical killing to minimize the load of resident flora. Clean surgical procedures, defined as those performed after surgical scrubbing with complete sterile technique, have an infection rate of 1% to 4%. Clean– contaminated surgery, in which minor breaks in sterile technique can occur, has an infection rate of 5% to 10%.5 Wounds in office-based cutaneous surgery can be classified as clean or clean–contaminated wounds depending on the procedure type, with infection rates
*Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina; †Section of Dermatology, Department of Medicine, Medical College of Georgia, Georgia Regents University, Augusta, Georgia; ‡Total Skin and Beauty Dermatology, Birmingham, Alabama © 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-0512 Dermatol Surg 2015;41:667–676 DOI: 10.1097/DSS.0000000000000375
·
·
667
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
ranging from 0.07% to 4.25%.5–8 Recent studies have found similarly low infection rates even without the use of prophylactic antibiotics.9 Additionally, guidelines recommend against the use of topical antimicrobial agents for wound healing by primary intention.10–12 A variety of antiseptics were routinely used in these aforementioned studies. The Surgical Site Bacteriology of the Skin Cutaneous flora includes both resident and transient bacteria. Resident bacteria are located primarily in the superficial epidermal layers. A minority (10%–20%) of resident cutaneous floras are in the deeper layers, particularly the pilosebaceous unit, making them more difficult to eradicate with antiseptic agents.13,14 The majority of these bacteria tend to be nonpathogenic and can prevent colonization of the skin with pathogenic bacteria.15 Resident cutaneous floras are found more commonly in creases and folds, particularly in the intertriginous areas.15 Transient floras are temporary inhabitants acquired by contact that are unable to colonize the skin. They are present superficially, loosely attached, and can be easily removed with scrubbing.4,15 Transient floras are the cause of the majority of postoperative wound infections.16 Both the resident and transient floras are influenced by host factors including sex, age, personal health, nutritional status, and location.17 Staphylococcus aureus is the bacteria most commonly implicated in SSIs. This bacteria usually starts as transient flora and transitions to resident flora with sustained inoculation.15 Increasing incidence of antimicrobial resistance of S. aureus has raised concern for treatment-resistant infections.18 Other common bacteria in SSIs include coagulase-negative Staphylococcus, Enterococcus, Escherichia coli, group A streptococci, and Pseudomonas aeruginosa.4,13,16,19 Hair Removal The 1999 Centers for Disease Control and Prevention (CDC) guidelines strongly discourage hair removal before surgery unless it will interfere with the procedure.
668
If removal is deemed necessary, the recommendation is that the hair be clipped immediately before the operation, preferably at a level just above the cutaneous surface with minimal, if any, contact with the skin during clipping.3,20 Preoperative shaving has been linked with an increased risk of SSIs. These are thought to be secondary to microabrasions on the cutaneous surface that facilitate postoperative bacterial growth and subsequent infection.13,21 A recent Cochrane review supported the existing CDC guidelines but acknowledged that most of the clinical trials investigating this subject are underpowered and more research is needed.22 Preoperative Decolonization The 1999 CDC guidelines strongly recommend preoperative antiseptic showering, with the use of products containing chlorhexidine gluconate (CHG) to reduce cutaneous bacterial colonization.3 Antiseptic body washes have been studied in a variety of formulations, including 4% CHG wash, 2% CHG impregnated cloths, alcohol-based products, and 10% povidone–iodine (PVP-I) scrub.19,23–27 Numerous studies have demonstrated significantly decreased bacterial colonization rates using these preoperative body washes.23,27–29 However, recent reviews have been unable to show definitive evidence that preoperative showering reduces SSI.30–32 There is increasing evidence that in patients with known carriage of S. aureus, preoperative decolonization may reduce the rate of SSI. It has been shown that nasal carriage of S. aureus is an independent risk factor for the development of SSI in multiple surgical settings, including dermatologic surgery.33–37 Investigations from various surgical disciplines have shown a reduction in SSI to a rate comparable with noncarriers with the use of protocols to identify and decolonize carriers of S. aureus before surgery.38–41 It remains to be seen if these interventions are beneficial in a dermatologic surgery setting, but a recent prospective randomized study demonstrated a significant reduction in SSI after Mohs surgery among nasal S. aureus carriers with the use of a topical decolonization regimen.37 A variety of decolonization protocols have been described, usually consisting of topical agents used
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
alone or in combination with oral antibiotics.38,39,41,42 Topical decolonization regimens commonly use a combination of CHG body wash once daily plus intranasal mupirocin ointment twice daily for 5 days before surgery. Cherian and colleagues42 recently reported an unblinded randomized controlled trial, which showed that topical decolonization was superior to prophylactic oral antibiotics at reducing the rate of SSI in 693 patients undergoing Mohs surgery who demonstrated nasal carriage of S. aureus. These results suggest that patients with known S. aureus carriage should be considered for topical decolonization before dermatologic surgical procedures, but more research is needed to confirm the validity of these findings. Surgical Attire Centers for Disease Control and Prevention guidelines state that shoe covers should not be worn for the prevention of SSI, which is supported by a 2003 literature review, which failed to find support for use of shoe covers to prevent SSI.12,43,44 The use of sterile gloves (SG) versus nonsterile gloves (NSG) in Mohs micrographic surgery (MMS) is still a matter of debate. Although studies have demonstrated a statistically significant difference in bacterial load favoring use of SG, the clinical significance of this finding is uncertain.45 A large prospective cohort study of MMS cases demonstrated an absolute risk reduction of 20.47% with the use of SG, but this small risk reduction may not correlate with clinical significance in the setting of overall low infection rates in MMS.46 Furthermore, a more recent study demonstrated that the prevalence of SSI in SG versus NSG was almost identical, and the cost of SG is 3.5 times greater.47 A recent Cochrane review evaluating the use of disposable face masks for preventing SSI in clean surgery identified 3 studies, which demonstrated no statistically significant differences between masked versus unmasked SSI rates; however, because of the small number of trials and limitations of the included studies, it is currently unclear if the use of surgical face masks alters SSI rates.48 Antiseptic Scrubs Adequate surgical antisepsis should remove all transient bacteria from the skin, while minimizing the remaining resident flora residing in the pilosebaceous
units.16 Recommendations have included using a detergent to remove physical debris from the skin, followed by an antiseptic scrub to kill bacteria.15 Scrubbing has been considered to be more important for disinfection than the type of agent used; a 50% reduction in bacteria has been described for every 6 minutes spent scrubbing.15 However, the importance of a full 5-minute scrub in directly preventing SSIs has been challenged and currently is not used by most dermatologic surgeons.49 The ideal antiseptic agent should be capable of killing all bacteria, fungi, viruses, protozoa, and spores present on host skin while remaining nontoxic, hypoallergenic, safe for use in all body regions, and nonabsorbable percutaneously to reduce systemic side effects and toxicity.4 Fast onset of action, continued residual antimicrobial activity, and safety and efficacy with repeated use are also desireable.4 As antiseptics have the risk of bacterial contamination with repeated use from the same receptacle, the ideal agent would be in single-use packets.15 Alcohol Alcohol is effective against Gram-positive and Gramnegative bacteria and many fungi and viruses.4 However, alcohol is not effective against most spores.13 Alcohol has been shown to inactivate HIV in vitro, but this effect was measured after contact times between 2 to 10 minutes.50 Therefore, it should not be relied on for this purpose in normal clinical settings because of its rapid evaporation. Blood and other organic compounds do not affect the antimicrobial action of alcohol.19 Alcohol provides fast acting antisepsis, but its lack of continued antimicrobial effect with drying precludes its stand-alone use.21,51 The utility of alcohol lies in its combination with more persistent antiseptic agents such as iodophors or CHG. These combinations provide more persistent antimicrobial activity that can last for the duration of surgery.21,51 Alcohol also has a role in developing countries where alternative antiseptics may not be available.52 When choosing an alcohol-based regimen, isopropyl alcohol is preferred over ethyl alcohol because of its superior antibacterial spectrum and less volatile nature.13 Alcohol and alcohol-based antiseptics are flammable if the product is still wet on the skin, and there have been
41:6:JUNE 2015
669
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
burns related to fire from electrosurgery after use of alcohol-based antiseptics.53,54 To prevent fires, alcohol should be given adequate time to dry, avoided in hair bearing areas where drying may be impaired, and pooling of the product should be prevented.21,54 Chloroxylenol Chloroxylenol is an antiseptic that is no longer commonly used because of its decreased efficacy in comparison with chlorhexidine and povidone–iodinebased products. One study demonstrated that the number of bacterial colonies after application of chloroxylenol was not statistically significant from the colony count on the skin before antiseptic application.55
heterogeneity in application method exists between studies with a range of time spent scrubbing and variable numbers of applications of PVP-I paint after scrub.4,14,28,49,52,62–69 This regimen of 5-minute scrub followed by painting is not performed by most dermatologic surgeons, as similar efficacy has been observed using the paint-only method.49,66,70 PVP-I should be allowed to dry fully after application for maximal antimicrobial effect.71 Drying time recommendations range from 2 to 20 minutes.67,71,72 A minimum of 2 minutes is recommended because iodophors require approximately 2 minutes of contact time to allow release of free iodine.72 If not removed from the skin, PVP-I can have sustained activity for 1 to 2 hours.15,73 Aqueous-Based Chlorhexidine
Aqueous-Based Iodophors Povidone–iodine (PVP-I), a combination of polyvinylpyrrolidone and iodine, is an iodophor that allows for steady release of iodine in a water-soluble product.2 The bactericidal effect of PVP-I is determined by the concentration of free iodine; a 10% PVP-I formula contains 1% available iodine.2–4 Iodophors are effective against a wide range of microorganisms including Gram-positive and Gramnegative bacteria, some bacterial spores, yeast, other fungal forms, protozoa, and viruses such as HIV, and hepatitis B virus (HBV).2,13,51,56 These are nonirritating to the eyes and mucous membranes, provide visibility to areas covered, and do not readily remove surgical markings.57 However, blood and serum proteins can inactivate PVP-I and prolonged or excessive application can cause systemic toxicity.3,15,51 PVP-I has been documented to cause an iododerma-like reaction and chemical burns.58,59 Anaphylaxis has occurred in patients with a systemic povidone–iodine allergy after topical use; therefore, topical PVP-I is not recommended in those with a history of systemic allergy.59,60 Although impaired wound healing has been demonstrated with direct application of PVP-I into wound beds, this seems not to be significant clinically.2,61 Traditional application involves a 5minute scrub with PVP-I surgical scrub followed by rinsing with sterile gauze saturated with water, then painting of the surgical site with aqueous PVP-I solution as recommended by the manufacturer. However,
670
Chlorhexidine gluconate is a bisbiguanide that is bacteriostatic at low concentrations and bactericidal at higher concentrations.74,75 Chlorhexidine gluconate has efficacy against a wide range of Gram-positive and Gram-negative bacteria, many viruses including HIV and HBV, and some fungi.3,13,56,72,76–78 Higher concentrations correlate with lower bacterial load.79 It provides residual antimicrobial action by binding to the stratum corneum and is resistant to removal by alcohol.13 Manufacturer recommendations for application include a 2-minute swab of the surgical site followed by drying with a sterile towel, then an additional 2-minute application followed by towel drying. However, the actual methods used are heterogeneous and include a 5- to 7-minute CHG scrub alone or scrub followed by painting with CHG– alcohol or isopropyl alcohol solution.62,64–67 One source recommended not wiping the area dry of CHG after application to allow its persistent antibacterial effect.79 Drying is recommended before incision, but actual time to allow for adequate drying is rarely cited. Current recommendations include allowing for at least 2 minutes of contact time before surgical incision.79 Chlorhexidine gluconate produces limited irritation to the skin and can be used on the oral mucosa and is not inactivated by blood or other organic material.72 However, CHG is ototoxic and can cause conjunctival irritation.13 It has been reported to cause
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
damage to the corneal epithelium and even lead to permanent corneal opacification.80 A test of rabbit corneas showed 4% chlorhexidine and 4% isopropyl alcohol with detergent to be toxic to the cornea.81 A study of ototoxicity performed on cats showed that application of chlorhexidine (2% and 0.05%) produced damage to the sensory epithelium resulting in a sensorineural hearing loss.82 This effect of chlorhexidine seems to be related to its concentration, and the clinical severity of injury often progresses over several weeks after exposure.83 It has also been shown to erase surgical site markings significantly more than PVP-I.84 Additionally, anaphylaxis has been demonstrated in response to topical application of CHG.85
Chlorhexidine Alcohols The combination of alcohol and CHG benefits from the potency of the alcohol and the persistent activity of the CHG. The mechanism of antimicrobial action of CHG–alcohol is attributed to the combined mechanisms of each of the products. The most popular agent is ChloraPrep (CareFusion, Inc., El Paso, TX), which contains 2% CHG and 70% isopropyl alcohol (CHG-IA), and has a duration of action of 48 hours.88 Chlorhexidine gluconate-IA should be applied for 30 seconds to dry surgical sites and should be allowed to dry for at least 30 seconds. For moist surgical sites such as the inguinal folds, 2-minute application followed by 1-minute drying time is recommended by the manufacturer; however, variable drying times ranging from 3 to 10 minutes were used in clinical studies.84,87
Alcohol-Based Antiseptics Product Comparisons Povidone–Iodine Alcohols Povidone–iodine–ethanol (PVP-I-ethanol or PI-ethanol) has the mechanism of action of PVP-I combined with that of alcohol. The alcohol allows for rapid acting antisepsis of the product, and the combination of alcohol with PVP-I increases the free iodine concentration higher than with PVP-I alone.51 Current available options include DuraPrep (3M Health Care, St. Paul, MN) and Prevail-FX (Cardinal Health, Dublin, OH). DuraPrep is iodine–povacrylex with 0.7% available iodine and 74% isopropyl alcohol by weight (wt/wt) (PI-IA), whereas Prevail-FX is PVP-I and a polymer complex with 0.83% available iodine dissolved in isopropyl alcohol 72.5% (wt/wt) (PVP-IA). Application of both products involves painting a single uniform coat over the operative site; excess product can be removed with absorbent towels or gauze. Both products form a water-resistant (PVP-IA) or water-insoluble (PI-IA) film on the surface of the skin with drying, which contributes to a duration of action of 48 hours or more.73,86 Recommended drying time is at least 2 to 3 minutes, but a longer 5-minute drying time should be considered when electrosurgery will be used to avoid fires.54 Although the film is resistant to removal by saline, which is thought to increase its antimicrobial efficacy, it can be difficult to remove after surgery is complete and may not be practical for brief procedures.16,87
PVP-I seems to have the broadest spectrum of action with excellent coverage of Gram-positive bacteria and good coverage of Gram-negative bacteria, Mycobacterium tuberculosis, fungi, viruses, and spores. Alcohol and CHG have similar spectrums of action, although alcohol is not sporicidal, and CHG has limited activity against the tubercle bacillus and fungi.72 However, it is not clear if these differing spectrums are clinically significant as the vast majority of wound infections are due to bacteria. The small infection rate in clean surgery makes appropriate powering of studies difficult. One study comparing over 1,800 patients using PVP-I versus normal saline had an infection rate of 0%.89 Smaller studies have shown superiority of aqueous- and alcohol-based CHG over PVP-I in reducing both bacterial colony counts and SSIs.62–65,88,90 A recent multicenter prospective cohort study of 20,821 MMS cases found that preoperative use of chlorhexidine was associated with a lower risk for infection.46 However, a 2009 Cochrane review found insufficient evidence in high-quality studies to recommend one antiseptic over another.4 Recent meta-analyses comparing alcohol- and aqueous-based CHG with aqueous PVP-I show superiority for CHG in preventing SSI in a variety of surgical procedures.66,67 These same results have been seen in a meta-analysis on catheter site
41:6:JUNE 2015
671
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
672
Antiseptic Alcohol
MOA Denatures proteins
Antimicrobial Coverage Gram-positive and Gram-negative bacteria, many fungi, and viruses
Onset
Duration Negatives/Risks Examples
Rapid
Short acting
Not active against bacterial spores Aqueous-based Free iodine oxidizes and iodophors substitutes microbial contents causing protein and DNA damage
Gram-positive and Gram-negative bacteria, yeast, and other fungal forms, protozoa, some viruses (HIV, HBV), and some bacterial spores
Intermediate
Intermediate
Alcohol-based iodophors
Rapid
Alcohol-based CHG
MOA of alcohol combined with that of aqueous CHG
Improved Gram-negative bacterial coverage
Improved Gram-negative bacterial coverage
Isopropyl alcohol
Short duration of action
Ethyl alcohol
Inactivated by blood and serum proteins
$0.03*
Betadine
$0.19*
Hibiclens
$0.31*
DuraPrep
$3.08†
Risk of skin reaction with iodine sensitivity
Aqueous-based Depolarizes bacterial cell walls Gram-positive and Gram-negative CHG and damages the cytoplasmic bacteria, yeasts, some other fungi, membrane, resulting in leakage many viruses, and prevents of cytoplasmic contents outgrowth but not germination of bacterial spores
MOA of alcohol combined with that of aqueous iodophors
1–2 h
High flammability risk
Cost per Application
6h
Prolonged or excessive application can cause systemic toxicity Ototoxic Causes conjunctival irritation Decreased visibility of surgical site markings compared with iodophors
Rapid
48 h
48 h
Skin irritation/ sensitivity related to iodine Film can be difficult to remove Risks of alcohol and CHG
Prevail-Fx ChloraPrep
*Pricing based on estimated volume per application of 15 mL. †Pricing based on application of a single 6 mL DuraPrep applicator. ‡Pricing based on application of a single 3 mL ChloraPrep One Step applicator. MOA, mechanism of action.
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
$1.08‡
ANTISEPTICS IN SURGERY
DERMATOLOGIC SURGERY
TABLE 1. Characteristics of Antiseptic Solutions
ECHOLS ET AL
preparation, with less catheter tip positivity and less blood stream infections.91 A recent large study by Darouiche and colleagues63 showed reduction of SSI by 41% with CHG-alcohol compared with aqueous PVPI. However, the perceived efficacy of CHG in skin antisepsis is often based on evidence for the efficacy of CHG-alcohol combination with failure to acknowledge the role of alcohol. A meta-analysis of the role of CHG in skin antisepsis found good evidence favoring CHG-alcohol combinations over aqueous PVP-I, but the superiority was not found to hold against PVP-I plus alcohol or other competitors combined with alcohol.92 In studies comparing PI–alcohol with PVP-I solution alone, there were no statistically significant rates of decreased infection.68,69,93 Chlorhexidine gluconate– alcohol has been shown to be more efficacious than PI– alcohol in decreasing bacterial colony counts after use in concentrations of 0.5%, 2%, and 4%.23,55,62,94 However, a recent large study of general surgery patients comparing PI–alcohol with CHG–alcohol and PVP-I showed a trend toward decreased SSIs in both the PI–alcohol and PVP-I groups when compared with CHG–alcohol.68 Skin irritation potential and product cost must also be taken into account when selecting the appropriate antiseptic. A comparison of 1% CHG–ethanol, 2% CHG–isopropyl alcohol, and 10% PVP-I solution demonstrated a trend of decreased skin irritation potential using 1% CHG–ethanol; larger studies are needed to determine if the difference is significant.95 Regarding cost, an observational study found that PVP-I skin disinfection is associated with systematic adjunctive costs from auxiliary materials and a significantly prolonged drying time compared with CHG leading to increased operating time; these adjunctive costs are considered to be on the same order of magnitude as the disinfectant cost itself.96 These additional costs are an important consideration when making direct per unit product cost comparisons (Table 1).
on demonstration of superior efficacy. Although numerous studies have demonstrated differences in bacterial colonization rates, few well-controlled investigations have demonstrated superiority of a given regimen. The alcohol-based iodophor and CHG products seem to exhibit greater efficacy than their aqueous-based counterparts. More randomized controlled trials will be needed to determine if any specific regimen is most effective. At this point in time, product usage should be based on specific attributes relating to the products, such as iodophors around the eyes and/or ears to avoid irritation and aqueous-based solutions in hair bearing areas because of concern for flammability. Ultimately, it is up to the individual surgeon to tailor the optimal antiseptic regimen for their specific scope of practice.
References 1. Polk HC, Cheadle WG, Franklin GA. Principles of operative surgery. In: Townshend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery: the biological basis of modern surgical practice (16th ed). Philadelphia: W.B. Saunders; 2001; pp. 163–170. 2. Goldenheim PD. An appraisal of povidone-iodine and wound healing. Postgrad Med J 1993;69:97–105. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250–78. 4. Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2004:CD003949. 5. Messingham MJ, Arpey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg 2005;31(8 Pt 2):1068–78. 6. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol 2003;139:143–52. 7. Whitaker DC, Grande DJ, Johnson SS. Wound infection rate in dermatologic surgery. J Dermatol Surg Oncol 1988;14:525–8. 8. Futoryan T, Grande D. Postoperative wound infection rates in dermatologic surgery. Dermatol Surg 1995;21:509–14. 9. Rogers HD, Desciak EB, Marcus RP, Wang S, et al. Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics. J Am Acad Dermatol 2010;63:842–51. 10. Welsh A, editor. Surgical site infection: prevention and treatment of surgical site infection. National Institute for Health and Clinical Excellence, National Collaborating Centre for Women’s and Children’s Health: London, 2008.
Conclusion
11. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia: Canberra ACT, 2010.
Currently, no definitive guidelines on surgical preoperative antisepsis indicate a specific regimen based
12. Merollini KMD, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline
41:6:JUNE 2015
673
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
recommendations and expert opinion. Am J Infect Control 2013;41: 221–6. 13. Sebben JE. Sterile technique and the prevention of wound infection in office surgery—part II. J Dermatol Surg Oncol 1989;15:38–48. 14. Jeng DK, Severin JE. Povidone iodine gel alcohol: a 30-second, onetime application preoperative skin preparation. Am J Infect Control 1998; 26:488–94. 15. Bennett RG. Microbiologic considerations in cutaneous surgery. In: Bennett RG, Fundamentals of cutaneous surgery. St. Louis: Mosby; 1988; pp. 136–78. 16. Ammirati CT. Aseptic technique. In: Robinson JK, Hanke CW, Siegel DM, Fratila A, editors. Surgery of the skin: procedural dermatology (2nd ed). St. Louis, MO: Elsevier, 2010; pp. 29–41. 17. Noparat W, Siripanichakorn K, Tribuddharat C, Danchaivijitr S. Persistence of antimicrobial effect of antiseptics in surgical hand hygiene regimens. J Med Assoc Thai 2005;88:177–82. 18. Klevens RM, Morrison MA, Nadle J, Petit S, et al. Invasive methicillinresistant Staphylococcus aureus infections in the United States. JAMA 2007;298:1763–71. 19. Seal LA, Paul-Cheadle D. A systems approach to preoperative surgical patient skin preparation. Am J Infect Control 2004;32:57–62. 20. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011:CD004122. 21. Segal CG. Infection control: start with skin: preoperative skin preparation systems help reduce surgical site infections. Nurs Manage 2006;37:46–52. 22. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2006: CD004122. 23. Veiga DF, Damasceno CV, Veiga-Filho J, Figueiras RG, et al. Povidone iodine versus chlorhexidine in skin antisepsis before elective plastic surgery procedures: a randomized controlled trial. Plast Reconstr Surg 2008;122:170e–1e. 24. Johnson AJ, Daley JA, Zywiel MG, Delanois RE, et al. Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthroplasty 2010;25:98–102. 25. Zywiel MG, Daley JA, Delanois RE, Naziri Q, et al. Advance preoperative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty. Int Orthop 2011;35:1001–6. 26. Murray MR, Saltzman MD, Gryzlo SM, Terry MA, et al. Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery. J Shoulder Elbow Surg 2011;20:928–33. 27. Veiga DF, Damasceno CV, Veifa-Filho J, Silva RV, et al. Influence of povidone-iodine preoperative showers on skin colonization in elective plastic surgery procedures. Plast Reconstr Surg 2008;121: 115–8.
33. Monge Jodra V, Sainz de Los Terreros Soler L, Diaz-Agero Perez C, Saa Requejo CM, et al. Excess length of stay attributable to surgical site infection following hip replacement: a nested case-control study. Infect Control Hosp Epidemiol 2006;27:1299. 34. Bozic KJ, Kurtz SM, Lau E, Ong K, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 2010;468:45. 35. Kurtz SM, Ong KL, Lau E, Bozic KJ, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468:52. 36. Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery 2003;134:S10–7. 37. Tai YJ, Borchard KLA, Gunson TH, Smith HR, et al. Nasal carriage of Staphylococcus aureus in patients undergoing Mohs micrographic surgery is an important risk factor for post-operative surgical site infection: a prospective randomized study. Australas J Dermatol 2013; 54:109–14. 38. Kim DH, Spencer M, Davidson SM, Li L, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 2010;92:1820–6. 39. Roa N, Cannella B, Crossett LS, Yates AJ Jr, et al. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 2011;26:1501–7. 40. Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871–7. 41. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, et al. Preventing surgical site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:9–17. 42. Cherian P, Gunson T, Borchard K, Tai Y, et al. Oral antibiotics versus topical decolonization to prevent surgical site infection after Mohs micrographic surgery—a randomized, controlled trial. Dermatol Surg 2013;39:1486–93. 43. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology, and prevention. J Hosp Infect 2008;70:3–10. 44. Santos AM, Lacerda RA, Graziano KU. Evidence of control and prevention of surgical site infection by shoe covers and private shoes: a systematic literature review. Rev Lat Am Enfermagem 2005;13: 86–92. 45. Creamer J, Davis K, Rice W. Sterile gloves: do they make a difference? Am J Surg 2012;204:976–9.
28. Magera JS, Inman BA, Elliott DS. Does preoperative topical antimicrobial scrub reduce positive surgical site culture rates in men undergoing artificial urinary sphincter placement? J Urol 2007;178: 1328–32.
46. Alam M, Ibrahim O, Nodzenski M, Strasswimmer JM, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol 2013;149:1378–85.
29. Edmiston CE, Okoli O, Graham MB, Sinski S, et al. Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. AORN J 2010;92:509–18.
47. Mehta D, Chambers N, Adams B, Gloster H. Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery. Dermatol Surg 2014;40:234–9.
30. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2012;9:CD004985. 31. Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, et al. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2012; 33:608–17.
674
32. Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control 2013;41:167–73.
48. Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev 2014;2:CD002929. 49. Ellenhorn JD, Smith DD, Schwarz RE, Kawachi MH, et al. Paint-only is equivalent to scrub-and-paint in preoperative preparation of abdominal surgery sites. J Am Coll Surg 2005;201:737–41.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ECHOLS ET AL
50. Van Bueren J, Larkin DP, Simpson RA. Inactivation of human immunodeficiency virus type 1 by alcohols. J Hosp Infect 1994;28: 137–48. 51. Nishimura C. Comparison of the antimicrobial efficacy of povidoneiodine, povidone-iodine-ethanol and chlorhexidine gluconate-ethanol surgical scrubs. Dermatology 2006;212:21–5.
71. Workman ML. Comparison of blot-drying versus air-drying of povidone-iodine-cleansed skin. Appl Nurs Res 1995;8:15–7. 72. Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control 1988;16:253–66. 73. Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol 2009;11:190–5.
52. Meier DE, Nkor SK, Aasa D, OlaOlorun DA, et al. Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country. World J Surg 2001;25:441–3.
74. Russell AD. Chlorhexidine: antimicrobial action and bacterial resistance. Infection 1986;14:212–5.
53. Weber SM, Hargunani CA, Wax MK. DuraPrep and the risk of fire during tracheostomy. Head Neck 2006;28:649–52.
75. Denton GW. Chlorhexidine. In: Block SS, ed. Disinfection, sterilization, and preservation (5th ed). Philadelphia: Lippincott Williams & Wilkins; 2001; pp. 321–336.
54. Tooher R, Maddern GJ, Simpson J. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004;74:382–5. 55. Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am 2005;87: 980–5. 56. Kawana R, Kitamura T, Nakagomi O, Matsumoto I, et al. Inactivation of human viruses by povidone-iodine in comparison with other antiseptics. Dermatology 1997(Suppl 2):29–35. 57. Keser A, Bozkurt M, Taner OF, Yorgancigil B, et al. Evaluation of antiseptic use in plastic and hand surgery. Ann Plast Surg 2005;55:490–4. 58. Masse M, Falanga V, Zhou LH. Use of topical povidone-iodine resulting in an iododerma-like eruption. J Dermatol 2008;35:744–7.
76. Modak S, Sampath L, Miller HSS, Millman I. Rapid inactivation of infectious pathogens by chlorhexidine-coated gloves. Infect Control Hosp Epidemiol 1992;13:463–71. 77. Montefiori DC, Robinson WE Jr, Modliszewski A, Mitchell WM. Effective inactivation of human immunodeficiency virus with chlorhexidine antiseptics containing detergents and alcohol. J Hosp Infect 1990;15:279–82. 78. Wood A, Payne D. The action of three antiseptics/disinfectants against enveloped and non-enveloped viruses. J Hosp Infect 1998;38:283–95. 79. Stinner DJ, Krueger CA, Wenke MJC. Time-dependent effect of chlorhexidine surgical prep. J Hosp Infect 2011;79:313–6.
59. Nahlieli O, Baruchin AM, Levi D, Shapira Y, et al. Povidone-iodine related burns. Burns 2001;27:185–8.
80. Phinney RB, Mondino BJ, Hofbauer JD, Meisler DM, et al. Corneal edema related to accidental Hibiclens exposure. Am J Ophthalmol 1988;106:210.
60. Le Pabic F, Sainte-Laudy J, Blanchard N, Moneret-Vautrin DA. First case of anaphylaxis to iodinated povidone. Allergy 2003;58:826–7.
81. Mac Rae SM, Brown B, Edelhauser HF. The corneal toxicity of presurgical skin antiseptics. Am J Ophthalmol 1984;97:221–32.
61. Kramer SA. Effect of povidone-iodine on wound healing: a review. J Vasc Nurs 1999;17:17–23.
82. Igarashi Y, Suzuki J. Cochlear ototoxicity of chlorhexidine gluconate in cats. Arch Otorhinolaryngol 1985;242:167–76.
62. Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine provides superior skin decontamination in foot and ankle surgery. Clin Orthop Relat Res 2005;438:204–8.
83. Willoughby K. Chlorhexidine and ototoxicity in cats. Vet Rec 1989; 124:547.
63. Darouiche RO, Wall MJ, Itani KF, Otterson MF, et al. Chlorhexidinealcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18–26. 64. Paocharoen V, Mingmalairak C, Apisarnthanarak A. Comparison of surgical wound infection after preoperative skin preparation with 4% chlorhexidine and povidone iodine: a prospective randomized trial. J Med Assoc Thai 2009;92:898–902. 65. Levin I, Amer-Alshiek J, Avni A, Lessing JB, et al. Chlorhexidine and alcohol versus povidone-iodine for antisepsis in gynecological surgery. J Womens Health 2011;20:321–4. 66. Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic review and meta-analysis of pre-operative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 2010;97: 1614–20. 67. Lee I, Agarwal RK, Lee BY, Fishman NO, et al. Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection. Infect Control Hosp Epidemiol 2010;31:1219–29. 68. Swenson BR, Hedrick TL, Metzger R, Bonatti H, et al. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol 2009;30:964–71.
84. Thakkar SC, Mears SC. Visibility of surgical site marking: a prospective randomized trial of two skin preparation solutions. J Bone Joint Surg 2012;94:97–102. 85. Okano M, Nomura M, Hata S, Okada N, et al. Anaphylactic symptoms due to chlorhexidine gluconate. Arch Dermatol 1989;125: 50–2. 86. Jeng DK. A new, water-resistant, film-forming, 30-second, one-step application iodophor preoperative skin preparation. Am J Infect Control 2001;29:370–6. 87. Stahl JB, Morse D, Parks PJ. Resistance of antimicrobial skin preparations to saline rinse using a seeded bacteria model. Am J Infect Control 2007;35:367–73. 88. Hibbard JS. Analysis comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs 2005;28:194–207. 89. Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study. Plast Reconstr Surg 2005;116:529–31. 90. Culligan PJ, Kubik K, Murphy M, Blackwell L, et al. A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet Gynecol 2005; 192:422–5.
69. Segal CG, Anderson JJ. Preoperative skin preparation of cardiac patients. AORN J 2002;76:821–8.
91. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002;136:792–801.
70. Zdeblick TA, Lederman MM, Jacobs MR, Marcus RE. Preoperative use of povidone-iodine. A prospective, randomized study. Clin Orthop Relat Res 1986;213:211–5.
92. Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012;7:e44277.
41:6:JUNE 2015
675
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANTISEPTICS IN SURGERY
93. Birnbach DJ, Meadows W, Stein DJ, Murray O, et al. Comparison of povidone iodine and Duraprep, an iodophor-in-isopropyl alcohol solution, for skin disinfection prior to epidural catheter insertion in parturients. Anesthesiology 2003;98:164–9. 94. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, et al. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am 2009;91:1949–53. 95. Nishihara Y, Kajiura T, Yokota K, Kobayashi H. Evaluation with a focus on both the antimicrobial efficacy and cumulative skin irritation potential of chlorhexidine gluconate alcohol-containing preoperative skin preparations. Am J Infect Control 2012;40:973–8.
676
96. Magalini S, Pepe G, Panunzi S, De Gaetano A, et al. Observational study on preoperative surgical field disinfection: povidone-iodine and chlorhexidine-alcohol. Eur Rev Med Pharmacol Sci 2013;17: 3367–75.
Address correspondence and reprint requests to: Kathryn Echols, MD, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 578, Charleston, SC 29425, or e-mail: ksfl[email protected]
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright of Dermatologic Surgery is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
