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Decreasing Surgical Site Infections
Abstract & Commentary
By Alison Edelman, MD, MPH, Associate Professor, Assistant Director of the Family Planning Fellowship Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Edelman is a consultant to Schering-Plough and receives grant/research support from the Society for Family Planning.
Synopsis: Chlorhexidine-alcohol scrub decreases surgical site infections in clean-contaminated surgical procedures (i.e., hysterectomies).
Source: Darouiche RO, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical site antisepsis. N Engl J Med 2010;362:18-26.
Darouiche and colleagues performed a u.s. multicenter randomized clinical trial of 849 patients undergoing clean-contaminated surgical procedures. Patients were randomized to chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. Intent-to-treat analysis was used. Primary outcome was surgical site infections within 30 days of the procedure. Demographics of the study population included: 10% in each group underwent gynecologic procedures, average age was 53 years, and a little under half of the study subjects in each group were female. In addition, approximately 25% of patients in each group underwent some sort of preoperative shower with chlorhexidine gluconate, povidone-iodine, or triclocarban, and 100% of patients received preoperative antibiotics. Surgical site infection was significantly lower in the chlorhexidine-alcohol scrub group (9.5% vs 16.1%; P = 0.004; relative risk, 0.59; 95% confidence interval, 0.41-0.85).
As more attention is placed on health care reform, including lower costs while improving performance, clinicians need lower tech tools to improve clinical outcomes. Surgical site infections account for approximately 15% of all nosocomial infections.1 In turn, these infections increase health care costs by lengthening hospital stays, increasing clinical costs, and increasing hospital readmissions.2 Darouiche et al provides us with one of the only randomized controlled trials comparing two commonly used surgical site preparations, chlorhexidine-alcohol scrub (Chloraprep®) and povidone-iodine scrub and paint (Scrub Care Skin Prep Tray®). Who knew that skin preparations for surgical site antisepsis, something that we use every day, has been so little studied?
The advantages of this study, besides its prospective randomized design, include that it was performed free of pharmaceutical support at six university-affiliated hospitals across the United States in both men and women undergoing a variety of clean-contaminated surgeries (colorectal, small intestinal, gastroesophageal, biliary, thoracic, gynecologic, and urologic). In addition, 100% of patients had antibiotics initiated preoperatively (Wow!). Its limitations include that comorbidities such as obesity or diabetes were not specifically reported but stated to be equal between groups (it would still be nice to know the numbers), approximately 50% of patients in each group received antibiotics postoperatively but it was not noted for how long, and 25% of patients underwent some sort of preoperative antisepsis shower. However, their randomization worked well with equal amounts of these adjunctive but not evidence-based anti-infection practices in both groups.3,4 Often, the results of studies are not easily generalizable for the practicing clinician, but this study did a good job of incorporating "gold-standard" study techniques while maintaining "real-life" practices.
The Centers for Disease Control and Prevention classifies surgical site infections into three different categories: superficial or deep incisional and organ space.5 Chlorhexidine-alcohol scrub (Chloraprep) was more protective against superficial and deep incisional infections (superficial: 4.2% vs 8.6%; P = 0.008; deep: 1% vs 3%; P = 0.05). There was no difference in rates of organ space infections between the two groups (4.4% vs 4.5%). One could speculate that skin antisepsis has little to do with organ space antisepsis, and with 100% compliance of systemic antibiotics in this study, this rate is as low as it can go.
This study provides us with high-level evidence to support a change in practice to start using chlorhexidine-alcohol scrub for surgical site antisepsis. Interestingly, there is emerging evidence that the increased effectiveness is due to the alcohol component and it may not matter if it is combined with chlorhexidine or iodine.6 If you do decide to use an alcohol-based preparation, a note of warning, adequate drying must be allowed prior to use to eliminate the risk of fire when using electrocautery. Copious amounts of hair can impede/delay the drying process (something to think about when you are near the vulva).6,7