The use of topical microbial agents in surgical skin antisepsis

Jaana Perttunen
MSc RN
Programme Manager
Jyväskylä University of Applied Sciences
Finland
E: [email protected]

Surgical site infections (SSIs) are a significant cause of mortality and morbidity.(1) It has been estimated that up to 15% of elective surgical patients and approximately 30% of patients whose surgical procedure was classed as contaminated will have an SSI.(2) There are plenty of factors that can cause SSIs, such as the microbes, patient characteristics, type and length of the operation and local circumstances. Individual factors do not necessarily cause an infection, but many risk factors together may increase the possibility of an SSI.(3) The aim of preoperative skin antisepsis is to reduce the risk of postoperative SSI by removing soil and transient organisms from the skin.(4)

Antiseptic agents
The skin is not a sterile surface. It is colonised by bacteria – up to three million micro­organisms per square centimetre.(5) There are two types of microorganisms on the skin: commensals and transients. Commensals are normally resident, while transients are not constantly present and are easily exchanged between individuals. Transients can be simply removed from the skin, but commensals are difficult to remove completely.(6) The removal of transient bacteria and reduction of the number of commensal organisms by antiseptic agents are recommended.(4,7,8)

There are several antiseptic agents available for preoperative preparation of skin. An ideal antiseptic agent has the following characteristics: it kills all bacteria, fungi, viruses, protozoa, tubercle bacilli and spores; it is nontoxic, hypoallergenic and safe to use in all body regions repetitively – an ideal agent has residual activity. The primary function of antiseptics includes both the mechanical removal and chemical killing and inhibition of the microbes. (6) Antiseptic agents should be used in accordance with the manufacturers’ written instructions.(4)

Products for skin antisepsis should be chosen carefully considering the patient’s condition.Antiseptic agents used on the skin may cause hypersensitivity reactions with adverse outcomes (eg, blisters, rashes).(4) Some antiseptic agents, such as chlorhexidine, may be absorbed by the skin or mucous membranes and become neurotoxic or ototoxic.(9) Certain antiseptic agents are believed to be potentially harmful to fetuses or neonates if used on pregnant women and/or nursing mothers.(4)

Iodophors (eg, povidone–iodine), alcohol-containing products and chlorhexidine gluconate are the most commonly used preoperative antiseptic agents. There are no well-controlled, operation-specific studies available that have adequately assessed the comparative effects of these agents on SSI risk.(1)

Iodine and iodophors
Iodine is rapidly bactericidal, fungicidal, tuberculocidal, virucidal and sporicidal. Aqueous or alcoholic solutions (tinctures) of iodine are associated with irritation and excessive staining. These problems were overcome by the development of iodophors.(10) Although germicidal activity is maintained, iodophors are considered less active against certain fungi and spores than tinctures.(11) Iodophors may be inactivated by blood or serum proteins, but have a bacteriostatic effect as long as they are present on the skin.(12)

Alcohol
Alcohol denatures the cell wall proteins of bacteria.(1) It is active against Gram-positive and Gram-negative bacteria, the tubercle bacillus and many fungi and viruses. The concentration of the alcohol is more important in determining its effectiveness than the type.(13) Ethyl alcohol is used 60–95% by volume in an aqueous solution, and isopropyl alcohol 50–91.3% by volume in an aqueous solution. Alcohol is easily available, is inexpensive and is the most effective and rapid-acting skin antiseptic. Aqueous 70–92% alcohol solutions have germicidal activity against bacteria, fungi and viruses, but spores can be resistant. The potential disadvantage of the use of alcohol in the operating room is its flammability.(1)

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Chlorhexidine
Chlorhexidine is probably the most widely used biocide in antiseptic products, in particular in handwashing and oral products, but also as a disinfectant and preservative. This is due in particular to its broad-spectrum efficacy, substantivity for the skin and low irritation.(14) Chlorhexidine gluconate is not inactivated by blood or serum proteins. According to the literature, preoperative handscrubs with chlor­hexidine gluconate achieved greater reductions in skin microflora than did povidone–iodine, and it also had greater residual activity after a single application.(1)

Preoperative skin preparation
Preoperative skin preparation includes preparations on the ward and in the operating room. According to the Association of periOperative Nurses (AORN), the surgical site should be assessed before skin preparation, and if there are any concerns in relation to the skin condition they should be noted and documented.(4) Whenever possible, hair should be left at the surgical site. If it is determined that hair should be removed, removal should be performed according to physicians’ orders and in a manner that preserves skin integrity.

The skin around the surgical site should be free of soil and debris. The effect on postoperative SSI rates of surgical patients showering with antiseptic agents has been studied. Several studies show that antiseptic preoperative showers or baths have been associated with reduced postoperative infection rates, but there are also controversial results.(1,15,16) Whole-body washing with chlorhexidine-containing detergent has been shown to reduce infections among neonates.(17) Preoperative showering or bathing with an antiseptic may be justifiable for some patients, but it has not definitively been demonstrated that it reduces SSI rates.(1,4) Showering with normal detergents, with accurate cleaning of skin creases, axillary space, groin, genitals and navel, is adequate to diminish the microflora of the skin.(18)

The efficiency of preoperative skin preparation is thought to be dependent on both the antiseptic agent and the method of application.(1) According to AORN, antiseptic agents used for skin preparation should be applied using sterile supplies, though data from one study suggest that a clean preparing kit may be as effective as a sterile kit for disinfecting skin.(4) On the other hand, Rantala et al suggest that the preparation kit does not have to be sterile but clean, such as the gloves used in skin preparation.(18)

When preparing the skin for a surgical procedure, there are some special matters that have to be considered. The areas of high microbial counts (eg, umbilicus, pubis, open wounds) within the surgical site should be prepared last. When the skin is burnt, denuded or traumatised, normal saline is recommended in skin preparation and the application of the skin preparation may need to be modified.(1,4) In cases where patients have certain medical conditions (eg, diabetes, skin ulcerations), gentle preparation techniques should be used. It is very important to prevent antiseptic agents pooling beneath patients, pneumatic tourniquet cuffs, electrodes or electrosurgical unit dispersive pads to reduce the risk of chemical burns. The antiseptic agents should be allowed a sufficient contact time before applying sterile drapes to achieve maximum effectiveness of the agent.(4) Where alcoholic solutions are used, an adequate drying time should be allowed as the solution is flammable (see www.medical-devices.gov.uk).

The patient’s skin is prepared by beginning in the area of the proposed incision. The prepared area should be large enough to extend the incision or create new incisions or drain sites if necessary.(1,4) A dedicated instrument or glove with a sponge, or an X-ray-detectable swab should be used. The applicator should be discarded once the periphery of the surgical site has been reached.(1)

Conclusion
The cause of SSIs is the sum of different risk factors. Diminishing the effect of a single factor, such as skin colonisation, improves the patient’s possibilities to recover from the surgery without SSI. Therefore, surgical skin antiseptics are highly recommended for preventing postoperative SSI, although Edwards et al suggest that further research in this particular area is still needed.(19)

References

1. Mangram A, Horan T, Pearson M, et al. Infect Control Hosp Epidemiol 1999;20:247-78.
2. Bruce J, Russell EM, Mollison J, Krukowski ZH. Health Technol Assess 2001;5:1-194.
3. Barie PS. Surg Infect 2002;3:S9-21.
4. AORN. Recommended practices for skin preparation of patients. AORN J 2002;75:184-7.
5. Hinchliffe S, Montague S. Physiology for nursing practice. 2nd ed. London: Baillère Tindall; 1988.
6. Larson E. Am J Infect control 1988;16:253-66.
7. Mangram AJ, Horan TC, Pearson ML, et al. Am J Infect Control 1999;27:97-132.
8. Leaper D, Orr K. Step: inflammation and infection. London: Royal College of Surgeons; 2001.
9. Boyce JM, Pittet D. Infect Control Hosp Epidemiol 2002;12:3-41.
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11. Rutala WA. Am J Infect Control 1995;23:313–42.
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13. Larson E. Am J Infect Control 1995;23:251-69.
14. Gardner JF, Gray KG. Chlorhexidine. In: Block SS, editor. Disinfection, sterilization, and preservation. 4th ed.Philadelphia (PA): Lea & Febiger; 1991.p. 251–70.
15. Lynch W, Davey PG, Malek M, et al. J Hosp Infect 1992;21: 179-91.
16. Roy M-C. Modern approaches to preventing surgical site infections. In: Wenzel PR, editor. Prevention and control of nosomical infections. 5th ed. Baltimore (MD): Wil liams & Wilkins; 2003. p. 369-84.
17. Meberg A, Schoyen R. Acta Paediatr Scand 1985;74:366-71.
18. Rantala A, et al. Hygienia kirurgisessa toiminnassa. In: Hellstén S, editor. Infektioiden (torjutana) torjunta kirurgiassa. 5th ed. Porvoo: WS Bookwell Oy; 2005. p. 254-61.
19. Edwards PS, Lipp A, Holmes A. Cochrane Database Syst Rev 2004;(3):CD003949.