A Randomized Controlled Trial of Povidone-Iodine Versus Chlorhexidine Gluconate With Isopropyl Alcohol for Preoperative Vaginal Antisepsis.

Many surgeons request use of 10% povidone-iodine (PI) for vaginal antisepsis; however, when PI is contraindicated, some surgeons request use of chlorhexidine gluconate (CHG) instead. The purpose of this randomized controlled trial was to determine any significant differences in self-reported symptoms associated with vaginal antisepsis with either 10% PI scrub or 4% CHG with 4% isopropyl alcohol. The control group comprised 62 participants who underwent vaginal antisepsis with the PI product, and the intervention group comprised 58 participants who underwent vaginal antisepsis with the CHG product. Participants completed surveys immediately before surgery, immediately after surgery, and 48 to 72 hours after surgery. No significant differences were found in the reported vaginal symptoms between the two groups for any survey. One participant in the intervention group reported symptoms consistent with an allergic reaction. Additional studies are needed on the use of CHG for vaginal antisepsis.

Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France.

BACKGROUND: Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols. AIM: To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation. METHODS: An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines. FINDINGS: In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated'). CONCLUSION: We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections.

OBJECTIVE: Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis. DESIGN: Retrospective cohort study. SUBJECTS: Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada. METHODS: Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI. MAIN OUTCOME MEASURE: Rates of endophthalmitis between the PI and CH groups. RESULTS: A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24). CONCLUSIONS: There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children?

National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11 years undergoing any surgical procedure with the use of an incision in the OR (N = 1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.

Biopsia en ortopedia y riesgo de contaminación bacteriana durante el muestreo de tejidos: hechos y estrategias / Biopsy in orthopaedics and risk of bacterial contamination during tissue sampling: facts and strategies

Las biopsias en el campo de la ortopedia se utilizan para guiar las opciones de diagnóstico y tratamiento para el proceso de la enfermedad que puede estar ocurriendo. La preparación de la piel de estas biopsias sigue la preparación estándar para un procedimiento quirúrgico, con el objetivo de disminuir la cantidad de microbiota que podría conducir a la contaminación del tejido de la biopsia e incluso a una posible infección. El tejido obtenido de la biopsia a menudo se somete a un studio histopatológico y cultivo. La tasa de contaminación bacteriana informada es aproximadamente inferior al 4%. Esta revisión cuestiona si las muestras de las biopsias se contaminan con la microbiota que permanece en la piel y cómo puede afectar el manejo. Además, qué técnicas o pasos pueden disminuir la tasa de contaminación al realizar una biopsia. Nuestra revisión bibliográfica identificó pocos estudios sobre la contaminación bacteriana de las biopsias. Identificamos diferentes factores implicados en el conocimiento de la microbiota de la piel: técnicas y soluciones de preparación de la piel, variación de la microbiota típica que coloniza la piel según la región anatómica, retención preoperatoria versus administración profiláctica de antibióticos y uso de diferentes hojas de bisturí para la piel superficial y para tejidos profundos, entre otros. Aunque no pudimos identificar ningún dato que proporcionara respuestas a nuestra pregunta original y cuantificar cada factor individualmente, la mayoría de los estudios en diferentes campos ortopédicos proporcionaron hallazgos significativos hasta cierto punto. Describimos algunas recomendaciones prácticas basadas en el consenso y la efectividad teórica para disminuir la tasa de contaminación. Se necesitan más investigaciones en el campo de la ortopedia que impliquen la contaminación por microbiota de la piel de una biopsia

Biopsies in the field of orthopaedics are used to guide diagnostics and treatment options for the disease process that may be occurring such as a tumor or infection. Skin preparation of these biopsies follows the standard skin preparation for a surgical procedure, with the aim to decrease the amount of microbiota that could lead to contamination of the tissue biopsy and even possible infection. The tissue obtained from the biopsy often undergoes pathology and culture. The reported bacterial contamination rate is roughly below 4%. This review questions how samples from the biopsies are getting contaminated by microbiota that remains on the skin and how it affects infection management. In addition, which techniques or steps can decrease the rate of contamination when performing a biopsy. Our review identified little to no data on investigating bacterial contamination of biopsies. In doing this, the review identified different factors implicated in skin microbiota awareness: skin preparation techniques and solutions, variation of typical microbiota that colonize the skin based on the anatomical region, preoperative withholding versus administrating antibiotics prophylactically and using different scalpel blades for superficial and deep incisions, among others. Although we failed to identify any data that provided answers to our original question and quantify each factor individually, most studies in different orthopaedic fields provided significant findings to some extent. We outline some practical recommendations based on consensus and theoretical effectiveness in decreasing the contamination rate. Further research entailing skin microbiota contamination of a biopsy is needed in the field of orthopaedics.

Disinfection, sterilization and antisepsis: An overview.

BACKGROUND: Each year in the United States there are approximately 100,000,000 outpatient/inpatient surgical procedures. Each of these procedures involves contact by a medical device or surgical instrument with a patient's sterile tissue and/or mucous membrane. A major risk of all such procedures is the introduction of infection. METHODS: We searched published literature for articles on the use and effectiveness of disinfectants, sterilization methods and antiseptics. RESULTS: The level of disinfection is dependent on the intended use of the object: critical (items that contact sterile tissue such as surgical instruments), semicritical (items that contact mucous membrane such as endoscopes), and noncritical (devices that contact only intact skin such as stethoscopes) items require sterilization, high-level disinfection and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program as well as other uses such as surgical hand antisepsis and pre-operative patient skin preparation. CONCLUSIONS: When properly used, disinfection and sterilization can ensure the safe use of invasive and non-invasive medical devices. Cleaning should always precede high-level disinfection and sterilization. Strict adherence to current disinfection and sterilization guidelines is essential to prevent patient infections and exposures to infectious agents.

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.

Effect of aqueous olanexidine versus alcohol-based chlorhexidine for surgical skin antisepsis on incidence of surgical site infections in gastrointestinal surgery: multicentre randomised controlled clinical trial (OEDO trial) protocol.

INTRODUCTION: Surgical site infections (SSIs) are among the most common nosocomial infections in surgery patients. Two types of preparations, povidone-iodine and chlorhexidine-alcohol, are commonly used in preoperative antiseptic procedures worldwide. However, there are inconsistencies among international guideline recommendations concerning skin antiseptics. This trial aimed to evaluate the superiority of olanexidine, which reduced SSI rates more than povidone-iodine in our previous randomised trial, over chlorhexidine-alcohol in clean-contaminated surgery. METHODS AND ANALYSIS: This multicentre randomised controlled clinical trial will compare two antiseptics (1.5% olanexidine and 1.0% chlorhexidine-alcohol) to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. On providing consent, patients aged <18 years will be included. The primary outcome will be the postoperative 30-day overall SSI rate, while the secondary outcomes will be the postoperative 30-day superficial incisional SSI rate, deep incisional SSI rate, organ/space SSI rate, positive bacterial wound culture rate, cultured bacterial strains, rates of intervention-related toxicity and allergic events (eg, erythema, pruritus, dermatitis and other symptoms of allergy around the region disinfected by the antiseptic during surgery), rate of reoperations due to SSI, medical economic effect indicators (based on health insurance claims) and hospital duration. The Mantel-Haenszel method will be used to estimate the adjusted risk ratio and its 95% CI for the primary analysis, which will compare the treatment effects. ETHICS AND DISSEMINATION: The protocol was approved by the Institutional Review Board of Keio University School of Medicine and subsequently by the board of each participating site. Participant recruitment began in January 2023. The final results will be published in medical journals after international peer review. TRIAL REGISTRATION NUMBER: UMIN000049712.

Guidelines in Practice: Hand Hygiene.

Effective hand hygiene is an important part of infection prevention, especially in perioperative areas. The revised AORN "Guideline for hand hygiene" provides perioperative personnel with evidence-based practice recommendations for hand hygiene. This article presents an overview of the guideline and discusses specific recommendations for maintaining appropriate fingernail and hand condition; wearing or removing hand and wrist jewelry; performing general hand hygiene; performing surgical hand antisepsis with a traditional hand scrub or surgical hand rub; selecting sinks, faucets, and drains to avoid hand contamination; and implementing quality activities to enhance hand hygiene compliance. It also includes a scenario illustrating how nurses can use the guideline to mitigate hand dermatitis associated with surgical hand antisepsis. Perioperative nurses should review the revised guideline in its entirety and apply the recommendations as applicable for their practice.

APPLICATION OF PROBIOTIC ANTISEPSIS FOR PURULENT COMPLICATIONS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS.

OBJECTIVE: The aim: To improve the results of surgical treatment of patients with type 2 diabetes and purulent-necrotic wounds by using probiotic antiseptics. PATIENTS AND METHODS: Materials and methods: 66 patients with type 2 diabetes and purulent-necrotic complications took part in this study. Probiotic antiseptics were used for local treatment in the experimental group (n=31), and traditional antiseptics were used in the control group (n=35). The levels of pro-inflammatory markers in the blood (IL-6, TNF-a, CRP) were studied; microscopic material was taken to study the type of cytogram during bandaging, before wound treatment with antiseptics or debridement on admission to the hospital (1st day), on the 3rd day and on the 7th day. RESULTS: Results: Analysis of dynamic changes in pro-inflammatory markers between the first and seventh days proved that only in the experimental group there was a statistically significant difference (IL-6 (Р=0.004), TNF-a (Р=0.001), CRP (Р=0.018)). Detection of regenerative-inflammatory and regenerative cytogram types on the 7th day in the experimental group had a statistically significant difference compared to the control group (p=0.002 and p<0.001, respectively). CONCLUSION: Conclusions: the use of probiotic antisepsis accelerates wound healing in patients with type 2 diabetes and purulent-necrotic complications.

Picture of Peri-Operative Antisepsis Practices (PPAP Survey) in France.

Abstract Background: Surgical skin preparation is performed according to peri-operative antisepsis protocols. These protocols are based on clinical practice recommendations and may vary from institution to institution. Materials and Methods: The objective of the survey, conducted among 481 surgeons and 98 scrub nurses of five specialties (cardiac, gastrointestinal, obstetrics and gynecology, orthopedics, and urology) in France was to take stock of practices to identify the protocols used for surgical skin preparation, such as measures relating to pre-operative showering, hair removal, or antisepsis of the operating area. Results: Two pre-operative showers with hair washing are usually carried out on the same day as the procedure (63%) or the day before the procedure (37%), mostly with an antiseptic (54%, soap 42%). Hair removal and cleaning/scrubbing are most often performed before the procedure (in 62% and 79% of cases, respectively). Alcoholic povidone-iodine is the most widely used antiseptic, and 81% of surgeons opt for complete spontaneous drying. Before making the incision, 41% of surgeons use drapes and 62% opt for an operative field irrigation technique during or at the end of the procedure. Surgeons mainly use running subcuticular sutures or running locking sutures (39%) and 93% use dressings. Thirty-six percent of the surgeons surveyed said the antisepsis protocols described were likely to be adapted. Conclusions: The results showed that international and French recommendations are mostly well followed by surgeons and scrub nurses in France. However, some differences are observed between surgical specialties, depending on the clinical situations encountered and the type of practice.

Best Practices and a Business Case for Surgical Site Infection Prevention.

Surgical site infections (SSIs) can be costly and result in prolonged hospital stays; readmissions; and additional diagnostic tests, therapeutic antibiotic treatments, and surgical procedures. Evidence-based practices for preventing SSIs include environmental cleaning; instrument cleaning, decontamination, and sterilization; preoperative bathing; preoperative Staphylococcus aureus decolonization; intraoperative antimicrobial prophylaxis; hand hygiene; and surgical hand antisepsis. Strong partnerships among infection prevention personnel, perioperative nurses, surgeons, and anesthesia professionals may enhance perioperative infection prevention. Facility and physician-specific SSI rates should be reported to physicians and frontline personnel in a timely, accessible manner. Together with costs associated with SSIs, these data help determine the success of an infection prevention program. Leaders can develop a comprehensive business case proposal for perioperative infection prevention programs. The proposal should describe the need for the program and anticipated return on investment; it also should focus on the goal of decreasing SSIs by establishing metrics for assessing outcomes and addressing barriers.

An interactive feedback system for increasing hand antisepsis adherence in stationary intensive care.

BACKGROUND: Pathogens causing infections are in many cases transmitted via the hands of personnel. Thus, hand antisepsis has strong epidemiological evidence of infection prevention. Depending on various factors, hand antisepsis adherence ranges between 9.1% and 85.2%. AIM: To evaluate a new transponder system that reminded medical staff to use an alcohol-based hand rub based on indication by giving real-time feedback, to detect hand antisepsis adherence. METHODS: The monitoring system consisted of three components: a portable transponder detecting alcohol-based hand rub and able to give feedback; a beacon recognizing entries to and exits from the patient's surroundings; and a sensor placed at the hand-rub dispensers to count the number of hand rubs. With these components, the system provided feedback when hand antisepsis was not conducted although it was necessary according to moments 1, 4, and 5 of hand antisepsis. Adherence was measured in two use-cases with five phases, starting with the baseline measurement followed by intervention periods and phases without intervention to test the sustainability of the feedback. FINDINGS: Using the monitoring system, hand antisepsis adherence was increased by up to 104.5% in comparison to the baseline measurement. When the intervention ceased, however, hand antisepsis adherence decreased to less than or equal to the baseline measurement. CONCLUSION: A short-term intervention alone is not sufficient to lead to a long-term change in hand antisepsis adherence. Rather, permanent feedback and/or the integration in a multi-modal intervention strategy are necessary.

Effect on the reduction of bacterial load after surgical hand antisepsis with triclosan 0.5% compared to triclosan 0.5% followed by 70% alcoholic solution.

Triclosan 0.5% by scrubbing does not meet the UNE-EN12791 criteria to be used in the surgical hand preparation (SHP). Triclosan 0.5% by scrubbing followed by ethanol 70% hand rubbing is suitable without the additional characteristic of sustained effect. This limited effectiveness implies that triclosan should be avoided in SHP given the restrictions on its use in consumer antiseptic products. The trial was registered at ClinicalTrials.gov (ID: NCT04538365).