Preop Skin Prep for Preventing Surgical Site Infections
Preop Skin Prep for Preventing Surgical Site Infections
Twenty studies of the comparative clinical effectiveness of preoperative skin antiseptic preparations provided information about presurgical showers, antiseptic preparation compared with nonmedicated soap, comparison of antiseptics, and draping. Two previous systematic reviews examined the effectiveness of presurgical showering for the reduction of skin flora and SSIs. The findings in these reviews were mixed. One found no evidence of the benefit of presurgical bathing with CHG, and the other found CHG bathing to be effective for reducing skin flora. These reviews were based on literature published before 2001. This review, which is based on more recent clinical trials, supports the idea that presurgical showering with CHG is effective for reducing bacterial burden, but the effect on SSIs was inconclusive. In 1 study, PI was used as a presurgical showering solution, and 2 studies compared PI surgical site preparation to soap and water or saline wound irrigation. None of these studies found a reduction in SSIs with PI use. Current clinical practice guidelines from the United Kingdom found that CHG showering or bathing reduces SSIs but is no more effective than soap and water.
Current Canadian practice guidelines recommend the use of CHG in alcohol for infection prevention; however, UK guidelines do not indicate a preference for a particular antiseptic. This review has been unable to draw conclusions about which surgical site antiseptic is most effective for reducing SSIs. These results are in contrast with those of 2 systematic reviews that suggest that CHG is more effective than PI for skin disinfection before surgery. These previous reviews considered some studies that were excluded from this review on the basis of a lack of postoperative assessment or inappropriate population or procedures of interest. The findings of this systematic review, however, agree with those of a previous review that indicated that there is insufficient evidence to support one antiseptic over another and with those of UK clinical practice guidelines that recommend the use of either CHG or PI for preoperative skin preparation.
Three studies described the use of iodophor-impregnated incise drapes with mixed results. Current UK evidence-based clinical practice guidelines also found mixed results and recommend iodophor-impregnated drapes when drapes are required. The guidelines also recommend against the use of nonantimicrobial drapes, but no studies making that comparison were identified for inclusion in this review.
The methodological quality of the studies was mixed. Evidence was drawn from RCTs and nonrandomized trials, although the method of randomization was generally poorly reported. Efforts were made to blind outcome assessors, but patients and surgeons often were not blinded, compromising internal validity. One study was performed in a pediatric population. Studies included a spectrum of surgical procedures and wound classifications, so the ability to form generalizations for all surgical patients is limited. Interventions and comparators were not always well described, and antisepsis methods varied between studies. This limits the ability to draw conclusions about specific concentrations and protocols but does provide information on the effectiveness of each antiseptic. Disinfectant products are sometimes mixed with an alcohol or an aqueous base. Because alcohol has antiseptic properties, this makes it difficult to make direct comparisons and form overall conclusions about a particular disinfectant.
Direct comparison of each study is difficult because of heterogeneity in antiseptic preparation, application technique, patient population, and study design. Estimates of the effectiveness of PI scrub or scrub and paint compared with soap and water are inconclusive; more research is needed to determine the optimal preparation, number, and timing of applications. Moreover, future research can assess the cost-effectiveness of the various antiseptic agents and preparation, since it remains to be determined.
In conclusion, the evidence suggests that preoperative showers with an antiseptic agent are effective at reducing bacterial colonization of the skin and may reduce SSIs. Because CHG was primarily used as the antiseptic with varying showering regimens and compliance rates in the included trials, the results remain inconclusive. Disinfectant products are often mixed with alcohol or aqueous base, which makes it difficult to form overall conclusions about an active ingredient. Large, well-conducted RCTs with consistent protocols are needed to provide evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.
Discussion
Twenty studies of the comparative clinical effectiveness of preoperative skin antiseptic preparations provided information about presurgical showers, antiseptic preparation compared with nonmedicated soap, comparison of antiseptics, and draping. Two previous systematic reviews examined the effectiveness of presurgical showering for the reduction of skin flora and SSIs. The findings in these reviews were mixed. One found no evidence of the benefit of presurgical bathing with CHG, and the other found CHG bathing to be effective for reducing skin flora. These reviews were based on literature published before 2001. This review, which is based on more recent clinical trials, supports the idea that presurgical showering with CHG is effective for reducing bacterial burden, but the effect on SSIs was inconclusive. In 1 study, PI was used as a presurgical showering solution, and 2 studies compared PI surgical site preparation to soap and water or saline wound irrigation. None of these studies found a reduction in SSIs with PI use. Current clinical practice guidelines from the United Kingdom found that CHG showering or bathing reduces SSIs but is no more effective than soap and water.
Current Canadian practice guidelines recommend the use of CHG in alcohol for infection prevention; however, UK guidelines do not indicate a preference for a particular antiseptic. This review has been unable to draw conclusions about which surgical site antiseptic is most effective for reducing SSIs. These results are in contrast with those of 2 systematic reviews that suggest that CHG is more effective than PI for skin disinfection before surgery. These previous reviews considered some studies that were excluded from this review on the basis of a lack of postoperative assessment or inappropriate population or procedures of interest. The findings of this systematic review, however, agree with those of a previous review that indicated that there is insufficient evidence to support one antiseptic over another and with those of UK clinical practice guidelines that recommend the use of either CHG or PI for preoperative skin preparation.
Three studies described the use of iodophor-impregnated incise drapes with mixed results. Current UK evidence-based clinical practice guidelines also found mixed results and recommend iodophor-impregnated drapes when drapes are required. The guidelines also recommend against the use of nonantimicrobial drapes, but no studies making that comparison were identified for inclusion in this review.
The methodological quality of the studies was mixed. Evidence was drawn from RCTs and nonrandomized trials, although the method of randomization was generally poorly reported. Efforts were made to blind outcome assessors, but patients and surgeons often were not blinded, compromising internal validity. One study was performed in a pediatric population. Studies included a spectrum of surgical procedures and wound classifications, so the ability to form generalizations for all surgical patients is limited. Interventions and comparators were not always well described, and antisepsis methods varied between studies. This limits the ability to draw conclusions about specific concentrations and protocols but does provide information on the effectiveness of each antiseptic. Disinfectant products are sometimes mixed with an alcohol or an aqueous base. Because alcohol has antiseptic properties, this makes it difficult to make direct comparisons and form overall conclusions about a particular disinfectant.
Direct comparison of each study is difficult because of heterogeneity in antiseptic preparation, application technique, patient population, and study design. Estimates of the effectiveness of PI scrub or scrub and paint compared with soap and water are inconclusive; more research is needed to determine the optimal preparation, number, and timing of applications. Moreover, future research can assess the cost-effectiveness of the various antiseptic agents and preparation, since it remains to be determined.
In conclusion, the evidence suggests that preoperative showers with an antiseptic agent are effective at reducing bacterial colonization of the skin and may reduce SSIs. Because CHG was primarily used as the antiseptic with varying showering regimens and compliance rates in the included trials, the results remain inconclusive. Disinfectant products are often mixed with alcohol or aqueous base, which makes it difficult to form overall conclusions about an active ingredient. Large, well-conducted RCTs with consistent protocols are needed to provide evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.
Source...