Enturia

35. Prevention of Perioperative Infection

Nicholas Fletcher, D’Mitri Sofianos, Marschall Brantling Berkes and William T. Obremskey. Prevention of perioperative infection (Current Concepts Review). The Journal of Bone and Joint Surgery. July 2007

The current article synthesizes the best available evidence regarding the use of preoperative antibiotics before elective and emergent orthopaedic operations, preoperative skin preparation of the patient and surgeon, operating-room issues, wound closure, operative drainage, and use of dressings in the hope that it will help physicians to reduce the incidence of postoperative wound infection. Based on the evidence, grades of recommendations were generated and intended to guide surgeons in determining whether they should change their practice on the basis of good (Grade-A) or fair (Grade-B) recommendations. Grade-A recommendations are derived from Level-I studies, whereas Grade-B recommendations are derived from Level-II or III research.

Preoperative Skin Antisepsis Supportive Facts Patient

• Chlorhexidine gluconate (CHG) acts to disrupt the cellular membranes of bacteria and if favored for its long-lasting activity against gram-positive and gram-negative organisms found on the human skin.
• Iodophors also act against common skin flora; however, their activity is much shorter than that of CHG
• CHG and povidone-iodine both reduce bacterial count on contact; however, this effect is sustained longer on skin cleansed with CHG
• Unlike CHG, the iodophors can be inactivated by blood or serum proteins and must be allowed to dry in order to maximize their antimicrobial action
• Alcohol is an excellent antimicrobial and has germicidal activity against bacteria, fungi, and viruses, but its effectiveness is limited by its lack of any residual activity and its flammability
• Quotes Ostrander in his finding that there were fewer bacteria on feet prepped with ChloraPrep than those prepared with DuraPrep^™ or Techni-Care^®. *(important note:  although there were fewer bacteria found on the feet of the Chloraprep group, the infection rates for all three groups were the same)
• Povidone-iodine impairs wound healing, even in concentrations of .5 %( 1/20^th) of those used in clinical practice, povidone-iodine is extremely toxic to fibroblasts and keratinocytes, thus povidone-iodine should not be used for the preparation of open wounds or on postoperative dressings
• The current literature strongly suggests that CHG is superior to povidone-iodine for preoperative antisepsis for patients and while alcohol is an excellent antimicrobial, its benefit is limited by its lack of residual activity. Use of a combination of CHG and alcohol (ChloraPrep) is perhaps the best way to take advantage of their antiseptic properties
• This article also mentions a recent meta-analysis that claims there is no difference in efficacy among the skin antiseptics used in clean surgery; however, the rarity of infection associated with these situations explains the low power of the included studies

Surgeon

• Compared with povidone-iodine, CHG surgical scrub provides a prolonged reduction in skin contamination with less toxicity and skin irritation
• Aqueous surgical hand-rubs are equivalent to traditional surgical hand-scrubs with regard to their ability to reduce bacterial contamination. However, surgeons comply with hand-rub protocols better than they comply with surgical scrub protocols (44% as compared to 28%; p=.008)
• The alcohol rub also decreased skin damage and required less time than the traditional CHG scrub.

Other Important Facts

• The use of antibiotic prophylaxis in orthopaedic surgery has been shown to be beneficial, as long as they target the usual infection organisms. Also, antibiotics should be administered within 60minutes prior to the incision and, ideally, as near to the time of incision as possible. Finally, antibiotics should be continued for no longer than 24 hours after elective surgery or surgical treatment of closed fractures.
• Whenever hair is removed, clippers, rather than a razor, should be used at the time of surgery.
• The use of impregnated plastic drapes (e.g., Ioban™, 3M) in conjunction with a skin antiseptic (DuraPrep™ or povidone-iodine) showed no significant evidence in reducing the prevalence of infection.
• Dressings act as a physical barrier to reduce the migrations of bacteria into the wound, a systematic review of 111 studies found that the rate of infection under occlusive dressings was lower than that under nonocclusive dressings (2.6% compared to 7.1%).
• The greatest source of airborne bacteria in the OR is the operating room personnel, with ears and beards being the two areas most likely to shed bacteria.
• SSI’s can be decreased by close control of perioperative glucose levels by maximizing patient oxygenation in the first 24 hours perioperatively and by maintaining patient normothermia in the perioperative period. Forty-four hospitals reported data on more than 35,000 patients during a trial to maximize control of glucose, oxygenation, and normothermia in the postoperative setting, and observed a decrease in infection rate from 2.3% to 1.7% over the course of the study
  (surgical infection occurred in 200 fewer patients)

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