1434

Wound infections occur in approximately 5% of pa-tients undergoing major abdominal surgery.1 Several fac-tors can contribute to the development of postoperativewound infections, some relating to the patient and someto the procedure itself.2 A key factor in preventing infec-tion is the elimination of bacterial contamination of theoperative site at the time of surgery.

The purpose of preoperative skin preparation is to re-duce bacteria on the skin before making an incision. Themost common method currently used to prepare the skinat the time of surgery involves scrubbing the operativesite with an antiseptic soap solution, followed by paintingthe site with an antiseptic paint solution after the soaphas been blotted dry.

The objective of this study was to compare a spray-onlytechnique to the traditional scrub-paint technique in re-ducing abdominal wall bacteria.

Material and methods

Sixty women scheduled to undergo vaginal surgerywere enrolled after informed consent was obtained. After

anesthesia had been administered, a blood agar plate(trypticase soy agar with 5% sheep blood) was directly ap-plied to the abdominal skin just above the umbilicus toobtain a control count of skin bacteria. Half of the ab-domen was then prepared with a traditional 5-minuteaqueous iodophor soap (10%) scrub and paint tech-nique. The other half of the abdomen was prepared withpovidone-iodine, 5% aerosol spray (Betadine, PurdueFrederick, Norwalk, Conn) that required 30 to 45 sec-onds to apply. No scrub was performed on the spray side.

Blood agar plates were applied directly to the skin after1 and 3 minutes in two separate areas on the spray side. Ablood agar plate was applied directly to the skin after the5-minute preparation on the scrub-paint side. The plateswere incubated at 37°C for 48 hours, and colony countswere performed. The percent reduction in bacteria wascalculated by subtracting the colony count after prepara-tion from the control colony count, dividing by the con-trol colony account, and then multiplying by 100.

For data analysis, multiple pairwise comparisons (scrubvs 1 minute after spray, scrub vs 3 minutes after spray, and1 vs 3 minutes after spray) were performed with theWilcoxon signed rank test. Comparisons of percent re-duction in bacteria were performed using paired samplest test. A P value of .05 was considered statistically signifi-cant in all analyses. The proportion of cultures with zerogrowth with each method is reported with a 95% CI.Analyses were performed with SSPS software (release10.0, SPSS, Chicago, Ill).

From the Division of Urogynecology, Department of Obstetrics and Gyne-cology, Advocate Lutheran General Hospital.Presented at the Twenty-eighth Annual Meeting of the Society of Gyneco-logic Surgeons, Dallas, Tex, March 4-6, 2002.Reprints not available from the authors.© 2002, Mosby, Inc. All rights reserved.0002-9378/2002 $35.00 + 0 6/6/129922doi:10.1067/mob.2002.129922

Povidone-iodine spray technique versus traditional scrub-painttechnique for preoperative abdominal wall preparation

Michael D. Moen, MD, Michael B. Noone, MD, and Inbar Kirson, MD

Park Ridge, Ill

OBJECTIVE: The study was conducted to compare povidone-iodine spray and traditional scrub-paint tech-niques in reducing abdominal wall bacteria during preoperative preparation.STUDY DESIGN: Sixty patients scheduled to undergo vaginal surgery were recruited for study. Cultures ofthe abdominal skin were performed before and after preparation with two techniques: a traditional 5-minuteiodophor soap scrub-paint on one half and povidone-iodine aqueous spray on the other. Multiple pairwisecomparisons were performed with the Wilcoxon signed rank test. A P value of .05 was considered statisticallysignificant in all analyses.RESULTS: The mean number of colonies for spray after 1 minute was 1.83 ± 3.16, for spray after 3 minuteswas 0.40 ± 1.15, and after 5-minute scrub was 0.87 ± 2.97. Both techniques, the spray after 3 minutes and the5-minute scrub, were statistically more effective at reducing bacterial counts than the spray after 1 minute.There was no statistically significant difference between the spray after 3 minutes and the scrub techniques.CONCLUSION: Povidone-iodine applied as a spray and left to dry for 3 minutes appears as effective as thetraditional scrub-paint technique in reducing abdominal wall bacteria before abdominal surgery. (Am J ObstetGynecol 2002;187:1434-7.)

Key words: Skin preparation, wound infection

Volume 187, Number 6 Moen, Noone, and Kirson 1435Am J Obstet Gynecol

Results

All control plates contained bacterial growth rangingfrom 2 to 300 colonies. The mean number of colonies oncontrol plates was 72.6 with 27 of 60 (45%) containing>100 colonies.

Data comparing scrub-paint, 1-minute spray, and 3-minute spray techniques is summarized in Table I. Themean number of colonies for spray after 1 minute was1.83 ± 3.16, for spray after 3 minutes was 0.40 ± 1.15, andafter a 5-minute scrub was 0.87 ± 2.97. This represented areduction in bacteria of 96.72% for spray after 1 minute,99.53% for spray after 3 minutes, and 98.89% for the 5-minute scrub. The proportion of cultures with zerogrowth was 0.57 (95% CI 0.44-0.70) for spray after 1minute, 0.82 (95% CI 0.72-0.93) for spray after 3 minutes,and 0.83 (95% CI 0.73-0.93) for the 5-minute scrub. Boththe spray after 3 minutes and the 5-minute scrub tech-niques were statistically more effective than the sprayafter 1 minute at reducing bacterial counts (3 minutes vs1 minute, P < .001 and scrub vs 1 minute, P = .003). Therewas no statistically significant difference between thespray after 3 minutes and scrub techniques in reducingabdominal wall bacteria (P = .5).

Comment

Wound infection is one of the most common seriouscomplications of gynecologic surgery, occurring in ap-proximately 5% to 10% of patients undergoing abdomi-nal hysterectomy.3,4 Although wound infection is apossible complication whenever an incision is made, fac-tors that increase the risk of wound infection are wellknown and can be separated into patient-related factorsand surgical factors. Patient factors include those relatedto the local wound, such as depth of adipose tissue andoxygen concentration, as well as systemic factors such aspoorly controlled diabetes, obesity, and malnutrition.2,4-6

Surgical factors include the type of procedure (clean,clean-contaminated, contaminated, and dirty) and dura-tion of operation.5

The most important factor in the development of awound infection is the presence of bacterial contamina-tion at the time of the surgical procedure. Lister7 is cred-

ited as the first author to suggest the use of antiseptictechnique during surgery to reduce bacterial contamina-tion and eliminate infection. Burke8 confirmed thatwound infections can be reduced by administering pro-phylactic antibiotics at the time of exposure to bacterialcontamination. Bacterial contamination can also be re-duced by using irrigation and, possibly by the use of ad-hesive drapes.9,10

The goal of preoperative skin preparation is to elimi-nate bacterial contamination at the surgical site. Al-though variation exists in techniques for skin preparationbefore surgery, one of the most commonly used tech-niques involves an initial scrub with antiseptic soap solu-tion, followed by painting the prepared area withantiseptic paint solution. Authors advocating this tech-nique suggest that mechanical friction on the skin is im-portant because it removes debris and nonviable cells.11

Studies comparing shaving and depilatory cream to re-move hair from the operative site suggest that mechanicalfriction on the skin during shaving has a deleterious ef-fect on maintaining sterility.12 Similarly, the use of scrubbrushes by operating room personnel has been shown toresult in higher bacterial counts than cleansing withoutbrushes.13

Some authors have found the use of paint-only techniques and the use of alcohol with iodophor-impregnated drapes to be as effective as the traditionalscrub-paint technique in reducing bacteria and prevent-ing wound infections.14-16 These techniques may be ef-fective because they avoid trauma to the skin at theoperative site.

The spray technique for preparation would also be ex-pected to minimize trauma to the abdominal wall skin.Potential advantages of the spray technique include re-duced time to perform preparation and reduced costcompared with current methods. Other potential advan-tages include ease and consistency of technique forpreparation, with potentially less risk of improper tech-nique, resulting in ineffective preparation.

Although the current data suggest that a 3-minutespray may be as effective as the traditional scrub-painttechnique in reducing abdominal wall bacteria, the abil-

Table I. Comparison of scrub-paint, 1-minute, and 3-minute techniques

Number of colonies after preparationScrub vs 1-min spray 0.87 (2.97) vs 1.83 (3.16) P = .0033-min vs 1-min spray 0.40 (1.15) vs 1.83 (3.16) P < .001Scrub vs 3-min spray 0.87 (2.97) vs 0.40 (1.15) P = .5

Mean percentage reduction in bacteriaScrub vs 1-min spray 98.89% vs 96.72% P = .023-min vs 1-min spray 99.53% vs 96.72% P = .001Scrub vs 3-min spray 98.89% vs 99.53% P = .23

Percentage of plates with zero coloniesScrub technique 83% (95% CI 73%-93%)1-min spray 57% (95% CI 44%-70%)3-min spray 82% (95% CI 72%-93%)

1436 Moen, Noone, and Kirson December 2002Am J Obstet Gynecol

ity of the spray technique to prevent wound infections re-mains to be proven. Despite reduction in bacteria at thebeginning of a surgical case, recolonization may occurduring surgery and contribute to the development of in-fection. The ultimate measure of the effectiveness of anypreparation technique is its ability to prevent postopera-tive infections. Our data support the undertaking of arandomized clinical trial comparing the effectiveness ofspray and scrub-paint techniques in preventing postoper-ative wound infections in patients undergoing abdominalsurgery.

We thank Nancy Davis for her assistance in the prepa-ration of this manuscript.

REFERENCES

1. Thompson JD. Incisions for gynecologic surgery. In: ThompsonJD, Rock JA, editors. TeLinde’s operative gynecology. 7th ed.Philadelphia: JB Lippincott; 1992. p. 239-77.

2. Lafreniere R, Bohnen JMA, Pasieka J, Spry CC. Infection controlin the operating room: current practices or sacred cows? J AmColl Surg 2001;193:407-16.

3. Taylor G, Herrick T, Mah M. Wound infections after hysterec-tomy: opportunities for practice improvement. Am J Infect Con-trol 1998;26:254-7.

4. Soper DE, Bump RC, Hurt WG. Wound infection after abdomi-nal hysterectomy: effect of the depth of subcutaneous tissue. AmJ Obstet Gynecol 1995;173:465-71.

5. Cruse PJE, Foord R. A five-year prospective study of 23,649 sur-gical wounds. Arch Surg 1973;107:206-10.

6. Greif R, Akca O, Horn EP, Sessler DI. Supplemental periopera-tive oxygen to reduce the incidence of surgical wound infec-tions. N Engl J Med 2000;342:161-7.

7. Lister J. On the antiseptic principal in the practice of surgery.BMJ 1867;2:246-8.

8. Burke JF. The effective period of preventive antibiotic action inexperimental incisions and dermal lesions. Surgery 1961;50:161-8.

9. Sindelar WF, Mason GR. Irrigation of subcutaneous tissue withpovidone-iodine solution for the prevention of surgical woundinfections. Surg Gynecol Obstet 1979;148:227-31.

10. French MLV, Eitzen HE, Ritter MA. The plastic surgical adhesivedrape: an evaluation of its efficacy as a microbial barrier. AnnSurg 1976;184:46-50.

11. Recommended practices for skin preparation of patients. AORNJ 1996;64:813-6.

12. Seropian R, Reynolds BM. Wound infections after preoperativedepilatory versus razor preparation. Am J Surg 1971;121:251-4.

13. Loeb MB, Wilcox L, Smaill F, Walter S, Duff Z. A randomizedtrial of surgical scrubbing with a brush compared to antisepticsoap alone. Am J Infect Control 1997;25:11-5.

14. Gilliam DL, Nelson CL. Comparison of a one-step iodophor skinpreparation versus traditional preparation in total joint surgery.Clin Orthop 1990;250:258-60.

15. Lorenz RP, Botti JJ, Appelbaum PC, Bennett N. Skin preparationmethods before cesarean section: a comparative study. J ReprodMed 1988;33:202-4.

16. Hagen KS, Treston-Aurand J. A comparison of two skin prepsused in cardiac surgical procedures. AORN J 1995;62:393-402.

Discussion

DR DONALD G. GALLUP, Savannah, Ga. Dr Moen and hiscolleagues have devised a well-designed study that chal-lenges our traditional techniques for preparing the ab-dominal skin for a surgical incision. His study uses the 60

patients as their own control. I should emphasize at theonset that this is a pilot study. All patients underwent vagi-nal surgery.

I will not reiterate all of his results. In summary, controlplates contained bacterial growth from 2 to 300 colonies,with a mean number of 73 colonies. Evaluation ofcolonies after the spray for 1 minute revealed a 96.7% re-duction in bacteria; after spray for 3 minutes, a 99.5% reduction in bacteria; and after scrub-paint for 5 minutes,a 98.9% reduction in bacteria. They note that no statisti-cal significance exists in reduction of bacteria when thespray was left to dry for 3 minutes compared with the tra-ditional scrub-paint technique.

In their Comment, Dr Moen and associates note thatthe spray technique may reduce time to perform skinpreparation and therefore reduce cost. Any time savedin the operating room is true cost savings for the pa-tient and the hospital. Time saved is also a “cost savings”for surgeons who are in the trenches, where minuteslost are critical. As I tell my residents, “Seconds add upto minutes, minutes add up to hours, hours add up todays; we don’t need to be here all day.” Not only are theinnovations presented today a savings to others, theyare a savings to us surgeons. Time saved in the operat-ing room arena can give us more time to see office patients.

In 1978, Galle et al1 showed, in an elegant study, that a5-minute no-brush scrub of surgeons’ hands was statisti-cally as effective as the then traditional 10-minute 2-brushtechnique. Currently, most operating rooms no longerhave signs at the scrub sink demanding a 10-minute sur-geon hand scrub.

The authors also suggest that a spray technique mini-mizes trauma to the abdominal skin wall. I agree. On thebasis of older studies, such as the classic article by Cruiseand Foord,2 most authors no longer shave the abdominalwall, but use a clip technique or depilatory creams to re-move hair from the operative site. At our institution, weuse a clip technique just before surgery to remove hairthat might interfere with the wound closure.

As also noted by the author, other disciplines have suc-cessfully reported the use of a 1-minute cleansing with al-cohol and the use of iodophor impregnated drapes.3,4

One must carefully apply these drapes. If these incisedrapes separate from the skin during the operation,wound infection rates have increased 6-fold.4

Dr Moen’s conclusions are on the money. The authorsremind us that theirs is a preliminary study. It does showequivalent reduction in abdominal wall bacteria whenthe 3-minute spray was compared with the traditionalscrub-paint technique. I thoroughly agree with theirstatement that a randomized clinical trial using these twomethods of skin preparation in patients undergoing ab-dominal procedures for gynecologic indications shouldbe done. The primary end point would then be the pre-

Volume 187, Number 6 Moen, Noone, and Kirson 1437Am J Obstet Gynecol

vention of wound infections is these patient groups. Thisis an excellent idea for the Research Committee of Soci-ety of Gynecologic Surgeons.

I have the following questions for Dr Moen:1. Was the consent form signed by the 60 women ap-

proved by the Institutional Review Board?2. Who performed the colony counts?3. Did any of the patients have preoperative “scrub”

showers the evening before or morning before surgery?(Noteworthy, 1 patient in the control group had only 2colonies on unprepared skin.)

REFERENCES

1. Galle PG, Homesley HD, Rhyne L. Reassessment of the surgicalscrub. Surg Gynecol Obstet 1978;147:215-8.

2. Cruse PJE, Foord R. A five year prospective study of 23,649 sur-gical wounds. Arch Surg 1973;107:206-10.

3. Geelhoed GW, Sharpe K, Simon GL. A comparative study of sur-gical skin preparation methods. Surg Gynecol Obstet1983;157:265-8.

4. Alexander JW, Aerni S, Plettner JP. Development of a safe and ef-fective one minute preoperative skin preparation. Arch Surg1985;120:1357-61.

DR MOEN (Closing). In response to Dr Gallup’s specificquestions: (1) An IRB-approved consent form was usedfor the study. (2) Colony counts were performed by fourdifferent technicians from the microbiology laboratory ofthe hospital. (3) None of the patients had “scrub show-ers” ordered as part of their preoperative preparation.

Bound volumes available to subscribersBound volumes of the American Journal of Obstetrics and Gynecology are available to

subscribers (only) for the 2002 issues from the publisher, at a cost of $122.00 for domestic,$156.22 for Canada, and $146.00 for international for Vol. 186 (January-June) and Vol. 187(July-December). Shipping charges are included. Each bound volume contains a subject andauthor index, and all advertising is removed. The binding is durable buckram with the Jour-nal name, volume number, and year stamped in gold on the spine. Payment must accompanyall orders. Contact Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL32887. Telephone (800)654-2452 or (407)345-4000. Fax (407)363-9661.

Subscriptions must be in force to qualify. Bound volumes are not available in place of aregular Journal subscription.