Evidence Based Practice Regarding Chlorhexidine Use to Prevent Surgical Site Infection

Evidence Based Practice Regarding Chlorhexidine Use to Prevent Surgical Site Infection

Presented by:

Cindy Magirl

Eric Nelson

Tennille Sassano

Jennifer Vicarie

What does the literature say about the use of Chlorhexidine in the prevention of surgical site infections (SSIs)?

It is estimated that between 750,000 and 1 million SSIs occur in the United States each year (Edmiston et al., 2010).

SSIs remains a substantial cause of post-operative morbidity and increased health care costs (Riley et al., 2012).

SSIs result in 3.7 million additional hospital days and $845 million spent nationally. (Zinn et al., 2010)

The aim is to evaluate the effectiveness of evidence-based prevention and control strategies to reduce rates of SSIs.

TABLE 1. Selected Patient and Procedural Characteristics Associated With Increased Risk of Surgical Site Infections

Patient (intrinsic)

Age

Diabetes (metabolic disease)

Perioperative hyperglycemia

Tobacco use

Concurrent infection (distant)

Obesity

Malnutrition

Immunocompromise

Low preoperative serum albumin level

Corticosteroid use

Prolonged hospitalization before surgery

Prior radiation to surgical field tissue

Staphylococcus aureus colonization

Procedural (extrinsic)

Lack of preoperative shower

Site shaving the night before surgery

Extended operative time

Flawed skin antisepsis

Flawed surgical prophylaxis

Effects of the OR environment (eg, hypothermia)

Break in aseptic technique

Hypothermia or hypoxia

Perioperative blood transfusion

Surgical technique

Hemostasis

Tissue trauma

Edmiston et al., 2010

Surgical Studies

1978 study showed that application of CHG to the skin surface resulted in a greater microbial log reduction and it persisted several hours after application compared with povidone iodine

1988 documentation shows that repeat application of CHG 4% was superior to a single shower in reducing staphylococcal skin contamination

Edmiston et al., 2010

Total Joint Replacement Surgical Study

PRE-INTERVENTION GROUP

727 patients

Self bathing of povidone iodine night prior to surgery

After 3 months, 3.19% infection rate

POST-INTERVENTION GROUP

737 patients

Self bathing of CHG 2% impregnated polyester cloths night prior to surgery and staff assisted bath on admission to hospital

After 3 months, 1.59% infection rate

Edmiston et al., 2010

8

Appraisal

Overall the evidence is strong in supporting the use of CHG. In the journal article, the authors identify some weakness within the studies they included. For example, in one of the studies the author lists several problematic issues involving study design, implementation, and analysis. Another weakness of this literature review is several studies were included and because of this, there was a lot of pertinent information left out in order to summarize the amount of information.

LOW TRANSVERSE CESAREAN SECTIONSURGICAL STUDY

Observational study conducted to determine LTCS SSI rates and impact of infection control interventions from Oct. 2005-Dec. 2008

Included use of 2% Chlorhexidine gluconate (CHG) for surgical skin prep and no rinse CHG cloths

Four study periods

Riley et. al, 2012

Low Transverse Cesarean Section (LTCS) Surgical Study Time Line

Baseline Period

(October, 2005 - March, 2006)

SSI rate retrospective identification for comparison

Riley et al., 2012

Low Transverse Cesarean Section (LTCS) Surgical Study Time Line

Outbreak Period

(April, 2006 October, 2006)

Obstetrics and gynecology (OBGYN) clinicians noticed an increase in post-LTCS patients returning with SSI in 2006

Focused on identifying critical control points and analyzing hazards by directly observing LTCS procedures

Labor and delivery (L&D) operating room (OR) walks

Self administered employee survey

Limited personnel traffic during surgery

Improved surgical hand scrub

Modified surgical skin preparation

Changed the timing of antimicrobial prophylaxis

Revised L&D OR policies

Performed SSI prevention in-services

Completed employee competency training

Low Transverse Cesarean Section (LTCS) Surgical Study Time Line

Intervention One Period

(November, 2006 September, 2007)

Focused on changing practice and fully implementing all recommendations from outbreak period

Fully implemented recommendations based on the CDCs SSI prevention guidelines

Low Transverse Cesarean Section (LTCS) Surgical Study Time Line

Intervention Two Period

(October, 2007 - December, 2008)

Chloroprep, a combination of 2% CHG and 70% isopropyl alcohol (IPA) replaced povidone-iodine for surgical skin prep

Implementation of preoperative CHG skin cleansing program

Scheduled patient performed night before surgery

Unscheduled nurse performed as part of pre-surgery prep

Moved into new hospital building

Changed administration time of antibiotic

Nurses in OBGYN clinics educated patients about SSI prevention

Appraisal

Evidence in itself was strong based on the reduction of SSIs during the study. However, there were also several limitations to the study:

Implementation of multiple interventions at the same time. Which intervention was successful?

Cost analysis was not studied in depth.

Although patients were instructed to contact their physician for signs and symptoms of infection, no official follow-up was coordinated.

Intra-operative Patient Skin Prep Agents: Is There a Difference?

The authors conducted an article review to evaluate if there is a superior intra-operative prep available for open abdominal and general surgery procedures.

The authors concluded that there is no one prep that is superior in all situations.

Zinn et al., 2010

Comparison of Prep Solutions

Povidone-iodine

Advantages

Excellent gram-positive activity

Good gram-negative activity

Broad spectrum

Moderate rapidly of action

Long established as an effective agent

Chlorhexidine

Advantages

Excellent gram-positive activity

Good gram-negative activity

Broad spectrum

Moderate rapidly of action

Excellent persistent and residual activity

Zinn et al., 2010

Comparison of Prep Solutions

Povidone- iodine

Disadvantages

Minimal persistence and residual activity

Decreased effectiveness in the presence of blood and organic material

Lack of recent empirical evidence

Chlorhexidine

Disadvantages

Contraindicated for use on eyes, ears, brain and spinal tissue, genitalia, mucus membranes

Inactivity in the presence of saline solution

Drying effect on the skin

Zinn et al., 2010

Appraisal

Only 29 studies were involved in this literature review

Each prep agent has specific advantages and disadvantages.

The study reviewed several prep agents because of the considerations for patient allergies, natural flora, surgical site, and surgeon preference.

The study did not include any research of ChloraPrep

The researchers stated that they did not find adequate information to prove one prep agent used exclusively.

The article was easy to read however lacked specific information or statistical evidence; leaving a lot of unanswered questions.

Decreasing methicillin-resistant staphylococcus aureus surgical site infections with chlorhexidine and mupirocin.

This was a case controlled study of 29,862 patients over a 3 year period

Only orthopedic, cardiac, neurological, and vascular cases were in the study

Thompson & Houston, 2012

Purpose of the study

To determine if a regimen of 2% chlorhexidine for 5 days pre-op along with intra-nasal mupiricin decreases MRSA surgical site infections

Thompson & Houston, 2012

Results

Cardiac 92% decrease

Orthopedic 43% decrease

Neurology 100% decrease

Vascular 52% decrease

Total MRSA SSI reductions from 2006-2008

Thompson & Houston, 2012

Appraisal

Pre-operative bathing with 2% chlorhexidine and use of mupiricin ointment may be beneficial in reducing MRSA SSIs

Our experience with CHG

We currently use a variety of products

ChloraPrep w/ tint

4% chlorhexidine solution

ChloraPrep SEPP

2% chlorhexidine cloths

Recommendations

Use of chlorhexidine intra-op skin prep when not contraindicated

Appropriate education to patients and staff about use and application

Pre-operative chlorhexidine bathing

Ongoing follow up on post operative infection rate

References

Edminster, C.E. Jr, Okoli, O., Graham, M.B., Sinski, S., & Seabrook, G.(2010). Evidence for using chlorhexidine gluconate preoperative cleansing to reduce risk of surgical site infection. Association of Perioperative Registered Nurses Journal, 92(5), 509-518.

Riley, M., Suda, D., Tabsh, K., Flood, A., & Pegues, D.(2011). Reduction of surgical site infections in low transverse cesarean section at a university hospital. American Journal of Infection Control, doi:10.1016/j.ajic.2011.12.011

Thompson, P., Houston, S. (2012). Decreasing methicillin-resistant staphylococcus aureus surgical site infections with chlorhexidine and mupirocin. American journal of infection control, 9(3).

Zinn, J., Jenkins, J., Swofford, V., Harrelson, B., & McCarter, S.(2010). Intraoperative patient skin prep agents: Is there a difference? Association of Perioperative Registered Nurses Journal, 92(6), 662-671. doi:10.1016/j.aorn.2010.07.016

References (Photographs)

CMPA Good Practices Guide. 2012. [Surgical Preparation]. Retrieved from http://www.cmpa-acpm.ca

Mayo Healthcare Pty. Ltd. n.d. Interventional Hygiene. Retrieved from http://www.mayohealthcare.com.au/products/Resp_intvHygiene_skinPrep.htm