Evaluation of Chlorhexidine Concentration on the Skin After Preoperative Surgical Site Preparation in Breast Surgery-A Randomized Controlled Trial.

BACKGROUND: Although there is a rationale supporting that preoperative showering with 2% or 4% chlorhexidine gluconate (CHG) would decrease skin bacterial colonization, there is no consensus that this practice reduces the risk of surgical site infection (SSI). OBJECTIVES: Analyze the skin concentration of CHG after preoperative showering associated with the traditional skin preparation with CHG 4% for breast surgery. METHODS: Randomized controlled trial that included 45 patients, all candidates for augmentation mammaplasty, allocated into three groups (A: no preoperative showering; B: one preoperative showering; C: two preoperative showering with CHG 4%) in a 1:1:1 ratio. Skin swabs collection was performed right before the surgical incision. The samples were, then, sent to spectrophotometry in order to determine the skin concentration of CHG at the beginning of surgery. RESULTS: The age ranged from 18 to 61 years, with a mean of 37 years old. Group C had the lowest median concentration (0.057) followed by group B (0.060) and group A (0.072), however, with no statistical significance. The areola was the place with the lowest median concentration level (0.045), followed by the axilla (0.061) and the inframammary fold (IMF) (0.069). Still, when comparing the distribution of the sites, a statistically significant difference was found only between the axilla and the areola (p = 0.022). CONCLUSION: Preoperative showering with CHG 4% did not increase the concentration of this agent on the skin surface right before the surgical incision. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

How to improve aseptic technique to reduce bloodstream infection during vascular access procedures.

Bloodstream infections associated with vascular access procedures pose a serious risk to patients that can be reduced by better standards of aseptic technique. The objectives of this roundtable of experts were to achieve a consensus on how to improve skin antisepsis in hospital, improve training, competency, compliance and consistency in skin antisepsis, review the role of devices in improving skin antisepsis, identify methods to improve skin antisepsis integrated with the Aseptic Non Touch Technique (ANTT®) approach, and identify challenges to the implementation of the panel's recommendations. Recommendations include using MHRA-licensed 2% chlorhexidine gluconate in 70% isopropyl alcohol solution with bidirectional strokes for up to 30 seconds, then leaving the skin to air dry for 30 seconds; using the ANTT Clinical Practice Framework and terminology as the standard for skin antisepsis training and practice; standardised ANTT and skin antisepsis education with 3-yearly competency assessments for all UK health professionals; and more research to address the evidence gap on transmission of infection after skin antisepsis.

Best practice skin antisepsis for insertion of peripheral catheters.

This article discusses the importance of effective skin antisepsis prior to the insertion of peripheral intravenous catheters (PIVCs) and how best clinical practice is promoted by application of an appropriate method of skin disinfection integrated effectively with a proprietary aseptic non touch technique, or other standard aseptic technique. Historically under-reported, incidence of infection and risk to patients from PIVCs is now increasingly being recognised, with new research and evidence raising concern and helping to drive new clinical guidance and improvement. The risks posed by PIVCs are particularly significant given increasing PIVC dwell times, due to cannula removal now being determined by new guidance for clinical indication, rather than predefined time frames. Clinical 'best practice' is considered in context of the evidence base, importantly including availability and access to appropriate skin antisepsis products. In the UK, and other countries, ChloraPrep is the only skin antisepsis applicator licensed as a drug to disinfect skin and help prevent infections before invasive medical procedures, such as injections, blood sampling, insertion of PIVCs and minor or major surgery.

Cutibacterium acnes persists despite topical clindamycin and benzoyl peroxide.

BACKGROUND: Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. METHODS: The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The McNemar test was used to compare the proportion of positive cultures in each group. RESULTS: C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide-clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide-clindamycin group. There were no statistically significant differences between treatment arms. CONCLUSION: The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

Solid lipid nanoparticles for targeted delivery of triclosan into skin for infection prevention.

Healthcare-associated infections (HAIs) are a concern for health service providers, exacerbated by poor delivery of antimicrobials to target sites within the skin. The dermal route is attractive for local and systemic delivery of drugs, however; permeation, penetration, and access to deeper skin layers are restricted due to the barrier function of the stratum corneum (SC). Solid lipid nanoparticles present several benefits for topical delivery for therapeutic applications, especially via the follicular route. Hair follicles, surrounded by a close network of blood capillaries and dendritic cells, are an important target for delivery of antimicrobials and present a unique microbial nidus for endogenous infections in situations where the barrier is disrupted, such as after surgery, for example, triclosan, a broad-spectrum antimicrobial agent, was encapsulated into nanoparticles using glyceryl behenate and glyceryl palmitostearate (GP) solid lipids, and incorporating Transcutol P, a known permeation enhancer at different ratios. Optimised formulation was stable over 90 d and in vitro permeation studies using full thickness porcine ear skin showed that the lipid-based nanoparticles enhanced delivery of triclosan into the skin and could direct the agent towards hair follicles, indicating their potential as a carrier system for antiseptic dermal delivery.

Surgical-site infection in gynecologic surgery: pathophysiology and prevention.

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

Impact of evidence-based interventions on wound complications after cesarean delivery.

BACKGROUND: A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence-based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine-alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine-alcohol vs iodine-alcohol for skin antisepsis at cesarean delivery from 2011-2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence-based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence-based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12-2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18-11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures. CONCLUSION: Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence-based measures.

Enhanced chlorhexidine skin penetration with 1,8-cineole.

BACKGROUND: Chlorhexidine (CHG) penetrates poorly into skin. The purpose of this study was to compare the depth of CHG skin permeation from solutions containing either 2% (w/v) CHG and 70% (v/v) isopropyl alcohol (IPA) or 2% (w/v) CHG, 70% (v/v) IPA and 2% (v/v) 1,8-cineole. METHODS: An ex-vivo study using Franz diffusion cells was carried out. Full thickness human skin was mounted onto the cells and a CHG solution, with or without 2% (v/v) 1,8-cineole was applied to the skin surface. After twenty-four hours the skin was sectioned horizontally in 100 µm slices to a depth of 2000 µm and the concentration of CHG in each section quantified using high performance liquid chromatography (HPLC). The data were analysed with repeated measures analysis of variance. RESULTS: The concentration of CHG in the skin on average was significantly higher (33.3% [95%, CI 1.5% - 74.9%]) when a CHG solution which contained 1,8-cineole was applied to the skin compared to a CHG solution which did not contain this terpene (P = 0.042). CONCLUSIONS: Enhanced delivery of CHG can be achieved in the presence of 1,8-cineole, which is the major component of eucalyptus oil. This may reduce the numbers of microorganisms located in the deeper layers of the skin which potentially could decrease the risk of surgical site infection.

Single vs Repeat Surgical Skin Preparations for Reducing Surgical Site Infection After Total Joint Arthroplasty: A Prospective, Randomized, Double-Blinded Study.

BACKGROUND: Preventing surgical site infection (SSI) after total joint arthroplasty (TJA) is a high priority and is partly linked to the efficacy of surgical site preparation solutions (SPSs) in reducing the number of pathogens on the skin before incision. The aim of this study is to investigate the effectiveness of SRS reapplication after draping to reduce the incidence of SSI after TJA. METHODS: Six hundred patients undergoing primary TJA between 2010 and 2011 at a single institution were recruited and randomly assigned to one of 2 groups. The patients in the intervention group (n = 300) received SPS that included alcohol and povidone-iodine before draping and an additional SPS by iodine povacrylex and isopropyl alcohol before application of the final adhesive drape, whereas the patients in the control group (n = 300) received a single SPS with alcohol and povidone-iodine before draping. Randomization was performed by an opaque envelope, and the rates of SSI and blistering were compared between groups. RESULTS: Five seventy-seven patients completed the study and were included in the final analysis. There was a significant reduction in the incidence of superficial SSI for the intervention group (1.8%, 5 of 283) compared to the control group (6.5%, 19 of 294, P = .02). There were 2 (0.7%, 2 of 294) deep incisional SSIs in the control group, and 2 (0.7%, 2 of 283) organ-space SSIs in the intervention group (P = 1.00). In addition, skin blistering was lower in the intervention group (3.5%, 10 of 283) vs the control group (6.5%, 19 of 294), but this difference also did not reach statistical significance (P = .13). CONCLUSION: Reapplication of an SPS after draping and before the application of iodophor-impregnated incisive draping resulted in a significant reduction in the rate of SSI in patients undergoing elective TJA.

Reducing Blood Culture Contamination Rates: Introduction of a Combined Education and Skin Antisepsis Intervention.

Background. Blood culture contamination (BCC) is an important quality concern in clinical microbiology as it can lead to unnecessary antimicrobial therapy in patients and increased workload for laboratory scientists. The Clinical Laboratory and Standards Institute recommend BCC rates to be <3 % and recently updated guidelines have set a new goal of 1 %. The aim of this project was to design and implement interventions to reduce BCC rates at our institution. Methods. We introduced a combined education and skin antisepsis intervention in a large Model 4 academic teaching hospital in the South of Ireland. BD ChloraPrep skin antisepsis applicators (2 % chlorhexidine gluconate/70 % isopropyl alcohol), licensed for use for blood culture specimen collection, were introduced, replacing Clinell (2 % chlorhexidine gluconate/70 % isopropyl alcohol) wipes. In addition, a multimodal education programme was designed and delivered. This consisted of a video demonstrating the recommended blood culture specimen collection technique using the new applicators as well as simulation training for all interns. The video was uploaded to the intranet as an educational resource available to all staff. Results. The interventions were implemented in July 2022 and BCC rates pre- and post-intervention were calculated. The average BCC rate for the 12 months preceding the intervention (July 2021 to July 2022) was 2.56 % with highest rates in the Emergency Department. This compared to an average rate of 2.2 % in the 12 months post-intervention (July 2022 to July 2023). In comparing the two rates the reduction in BCC rates between the two periods was not statistically significant (P=0.30). Conclusion. Overall BCC rates reduced but the difference between the two periods did not reach statistical significance. The resource-intensive nature of providing regular and timely feedback of contamination rates and the larger impact of in-person education and training over virtual modalities may explain the modest reduction. Further investments in these areas, particularly in the Emergency Department, will be necessary to further reduce rates in line with new recommendations.

Povidone Iodine vs Chlorhexidine Gluconate for Preoperative Skin Antisepsis: A Systematic Review and Meta-analysis of Randomised Controlled Trials.

BACKGROUND: Surgical site infection (SSI) remains a challenge in healthcare, contributing to prolonged hospital stays, increased healthcare costs, and adverse patient outcomes, including mortality. Effective preoperative skin disinfection interventions, such as povidone-iodine (PVI) and chlorhexidine (CHG), are widely used but their efficacy remains debated. To address this gap, this meta-analysis aims to evaluate the efficacy of PVI and CHG. METHOD: We searched PubMed, Embase, and Cochrane databases up to June 2024 to identify studies comparing PVI versus CHG for preoperative skin antisepsis. We calculated odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CIs). A random-effects model was used with statistical significance set at p < 0.05. Data were analysed using R software (version 4.4.0), and heterogeneity was assessed using I2 statistics. FINDINGS: Sixteen randomised controlled trials (RCTs) were included, involving a total of 13,721 patients, among whom 6,836 (49.8%) received PVI. Compared to CHG, PVI was associated with a non-significant reduction in deep SSI (OR 1.00; 95% CI 0.66 - 1.50; p = 0.994), but an increased risk of overall SSI (OR 1.25; 95% CI 1.06 - 1.48; p = 0.007) and superficial SSI (OR 1.67; 95% CI 1.25 - 2.24; p < 0.001). CONCLUSION: PVI as preoperative skin antisepsis demonstrated a non-significant reduction in deep SSI compared to CHG but was associated with an increased risk of overall and superficial SSI. Despite these findings, PVI remains an effective option, especially in resource-limited settings. Further research is needed to optimise its use and improve infection prevention strategies in clinical practice.

The Level of Surface Coverage of Surgical Site Disinfection Depends on the Visibility of the Antiseptic Agent-A Virtual Reality Randomized Controlled Trial.

BACKGROUND: Surgical site infections (SSIs) have a significant impact on outcome associated with surgical treatment. Therefore, skin antisepsis has evolved as a standard preoperative procedure in the operating room to reduce the perioperative risk of an SSI. In their "Global Guidelines for the prevention of surgical site infections", the World Health Organization (WHO) recommend the use of an agent with remanent additives and considers colored agents as helpful. However, colored and remanent disinfectants are not available in Germany. The aim of the present study was to investigate whether using a colored antiseptic solution increases the quality of preoperative skin antisepsis. METHODS: This study was designed as a randomized, double-blinded controlled trial. To examine the level of coverage of skin antisepsis, an appropriate virtual reality (VR) environment was generated. Participants could see a movable surgical clamp with a swab in their hand. When touching the skin, the participants recognized an optical change in the appearance of the skin: Using a colored antiseptic solution resulted in orange-colored skin. Using an uncolored agent, a shiny wet look was visible without a change in natural skin color. RESULTS: Data of 141 participants (female: 61.0% (n = 86); mean age: 28 y (Range 18-58 y, SD = 7.53 y)) were included in the study. The level of disinfection coverage was higher in the group using the colored disinfectant. On average, 86.5% (sd = 10.0) of the leg skin was covered when a colored disinfectant was used, whereas only 73.9% (sd = 12.8) of the leg skin was covered when the participants had to use an uncolored agent (p < 0.001, effect size: f = 0.56, η2 = 0.24). CONCLUSIONS: The use of an uncolored disinfectant leads to a lower surface coverage of the perioperative skin disinfection. Thus far, it is unclear whether using uncolored disinfectants is associated with higher risks for perioperative infections compared with the use of non-remanent disinfectants. Therefore, further research is necessary and current German guidelines should be re-evaluated accordingly.

Best products for skin antisepsis.

BACKGROUND: Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections. METHODS: A PubMed search was performed to update the evidence on skin antiseptic products and practices. RESULTS: Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs. CONCLUSIONS: Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.

The effect of preoperative skin preparation on clinical outcomes with incisional surgery: a network meta-analysis.

BACKGROUND: Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta-analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery. METHODS: The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk-of bias (ROB2) assessment was used. RESULTS: Twenty-nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09-1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment. CONCLUSION: Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.

Health care staff perceptions of gaps and education needs for patient-led preoperative hygiene using chlorhexidine gluconate skin cleansing products.

Through survey-led interviews, health care staff recognizes that patients have different bathing techniques and need more education on chlorhexidine gluconate cleansing. Preliminary findings gathered will be used to develop and test electronic competency-based tools to ensure patients are provided with the same comprehensive instructions before using chlorhexidine gluconate bathing products.

Optimizing skin antisepsis for neonatal surgery: A quality improvement initiative.

PURPOSE: Surgical site infections (SSIs) are a significant determinant of morbidity in the Neonatal Intensive Care Unit (NICU). Chlorhexidine gluconate/isopropyl alcohol (CHG-IPA) skin prep has demonstrated superiority over Povidone-Iodine (PI) in preventing SSIs in adults, however FDA labeling discourages CHG use in infants <2 months. This project aimed to i) create evidence for safe CHG skin antisepsis in neonates; and ii) evaluate the safety and effectiveness of CHG skin prep for neonatal surgery. METHODS: A literature review was conducted to assess the safety and effectiveness of neonatal CHG skin antisepsis. Following stakeholder engagement, a CHG surgical skin prep protocol and validated neonatal skin integrity tool to assess prep-associated skin injury were implemented in 50 consecutive, eligible neonates ≥1500 g and ≥34 weeks post conceptual age undergoing abdominal or thoracic surgery. SSI rates were compared to a matched, historical PI skin prep cohort. RESULTS: 2%CHG-70%IPA or 0.5%CHG-70%IPA were used based on gestational age cutoffs. None of the CHG patients experienced adverse skin prep outcomes while 8% developed SSIs, compared to 14% in the historical PI cohort. CONCLUSION: This project engaged NICU stakeholders in quality improvement work and informed the implementation of a safe and effective CHG skin prep protocol for neonatal surgery. LOE: IV.

Guidelines in Practice: Preoperative Patient Skin Antisepsis.

Surgical site infections (SSIs) frequently involve resident bacteria (eg, Staphylococcus aureus) on the patient's skin. Strategies to help prevent SSIs include removing soil and transient microorganisms from the skin before surgery. Preoperative decolonization, preoperative bathing, and application of an effective skin antiseptic at the surgical site are components of a multimodal approach to reducing microorganisms to subpathogenic levels. As members of an interdisciplinary team, perioperative RNs are essential in the development and implementation of SSI prevention bundles to promote patient safety. This article discusses recommendations from the AORN "Guideline for preoperative patient skin antisepsis" for decolonization protocols, preoperative bathing, and selection of surgical site antiseptics. A scenario describes the process a facility team uses to determine components of an SSI prevention bundle after recognizing an increase in infections from multidrug-resistant organisms.

Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region.

BACKGROUND: Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times. METHODS: Using a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. RESULTS: Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported. CONCLUSIONS: PVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.

PRE-INCISION SKIN ANTISEPSIS: PRACTICE PATTERNS AMONG SURGEONS IN NIGERIA.

Background: Although studies are rife on preoperative skin antisepsis, little is known about what surgeons in Nigeria practice. Objective: To describe the pattern of practice of skin antisepsis prior to skin incision among surgeons in select tertiary hospitals in Nigeria. Methods: This was a questionnaire-based descriptive cross-sectional survey involving surgeons and surgeons in training in the departments of surgery, obstetrics and gynaecology (O&G), otorhinolaryngology (ENT), and oral & maxillofacial surgery (OMS) of 26 select tertiary hospitals from all six geopolitical zones in Nigeria. Data was analysed using version 23 of the SPSS for Windows. Results: A total of 200 surgeons participated in the study with a male-to-female ratio of 9:1. The mean age was 37.2 ± 5.2 years. Senior registrars constituted 60.5% (n=121), followed by registrars (24%; n= 48) and consultants (15.5%; n= 31). The respondents performed a mean volume of 4 surgeries per week. Their most common practice is to perform skin preparation with 3 antiseptic agents with skin scrubbing lasting for 3-4 minutes. Skin scrubbing was performed for longer duration amongst consultants compared with senior registrars and registrars. Of all the surgical wounds encountered in their practice, 57%were clean. The common complications associated with the use of these antiseptic agents include allergic dermatitis and blisters. Conclusion: The practice of pre-incision skin antisepsis varies widely among Nigerian surgeons. The majority use 3 antiseptic agents for skin antisepsis although most of the procedures performed were clean surgeries. We recommend further studies to standardize our practice locally.

Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial.

BACKGROUND: Multimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery. METHODS: We performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions. RESULTS: From November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p = 0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p = 0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis. CONCLUSION: Skin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.