SURGICAL SITE INFECTIONS
Surgical skin prep: What effect does it really have?
Dr Andrew Kemp PhD (Bio), Dr Vanessa Hodgkinson MBBS, BSc, FRCA, FFPMRCA and Miss A Bugg MSc (Microbiology) explore the comparative effect on skin bacterial counts of three surgical skin preparations.
Surgical site infections (SSIs) occur in approximately 2% – 5% of patients who undergo clean extra-abdominal surgeries, such as thoracic and orthopaedic surgery, and in up to 20% of patients who undergo intra- abdominal surgery interventions.1, 51 SSIs can lead to increased morbidity and mortality and are associated with prolonged hospital stay and greater hospital costs.1, 39, 46, 51
The Institute for Healthcare
Improvement reports that SSIs in the United States increase the length of hospital stay by an average of 7.5 days, at an estimated cost of $130 million to $845 m per year.2
In 2006, SSIs
accounted for 14% of healthcare- associated infections in the United Kingdom, resulting in additional costs of between £814 and £6626, depending on severity.3 Microbial contamination of the
surgical site is a possible factor in the development of an SSI, prevention techniques aim to minimise the presence and spread of microorganisms. Prevention strategies include antibiotic prophylaxis, antiseptic prophylaxis, hair removal, perioperative glucose control, and maintenance of normothermia.4, 51
Topical antiseptics
may be applied to the skin preoperatively to reduce SSI risk. The main types of skin antiseptics
currently in use are, iodine or iodophor (such as povidone-iodine [PI]), ethyl alcohol, and chlorhexidine gluconate.5 CHG and PI can be mixed with either alcohol or water, which may have
implications for their effectiveness.6 Clinical practice guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend that patients shower or bathe with soap the day before - or the day of – surgery, and that iodophor-impregnated surgical drapes be used when incise drapes are required.3
They also recommend preparing the skin at the surgical site with antiseptic immediately before incision, but they do not indicate a preference for CHG or PI.3
effect’, where the act of measuring alters the outcome, is impossible to measure in studies looking at the link between skin disinfectant solutions and patient outcome.48
The significance of skin bacteria
As there is a significant difference in the colour of the liquid skin antiseptic, it is impossible to blind the selection of liquid to the surgical team, ward team and research team. The ‘observer effect’ or ‘Hawthorn
SSIs can lead to increased morbidity and mortality and are associated with prolonged hospital stay and greater hospital costs.
30 l JULY 2018 l OPERATING THEATRE
around surgical wounds, and its direct/ indirect effect as a cause of SSIs have therefore been well documented and recommendations have been made by agencies, such as the United States Centre for Disease Control (USCDC) and NICE in the UK.39, 40 However, in recent reviews of the
current available literature, the value of the studies used by these organisations has been brought into question.7,38,49 The authors’ conclusions in both reviews were similar: “The
methodological quality of the studies was mixed. Evidence was drawn from Randomised Controlled Trials (RCTs) and Non-Randomised Trials (NRTs), although the method of randomisation
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