Surgical Site Infections Reduced by Using Chlorhexidine

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The Centers for Disease Control and Prevention estimates that in American hospitals alone, there are 1.7 million healthcare-associated infections each year. Of these infections, 22% are surgical site infections (SSIs).

Surgical site infections result in longer hospital stays, in readmissions, and sometimes death. Healthcare providers continue to seek ways to further reduce these infections.

Two new prospective studies look at ways to reduce SSIs and are reported in the Jan. 7 issue of the New England Journal of Medicine. In an accompanying editorial, Richard Wenzel, MD states the articles offer "valuable insights for controlling surgical-site infections."

The chemical antiseptic chlorhexidine was found to be a more effective preoperative skin cleanser than povidone-iodine, resulting in fewer surgical site infections, even in carriers of Staphylococcus aureus.

Rabih Darouiche, MD and colleagues found using chlorhexidine as the preoperative skin cleanser reduced infections by 41% compared with povidone-iodine. Their study involve randomly assigning 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I). Patients were assessed for occurrence of SSIs within 30 days postoperatively.

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CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I), lower rates of superficial (4.2% vs. 8.6%) and deep (1.0% vs. 3.0%) incisional SSIs. There was no significant difference between the two groups where organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%) was involved.

Lonneke G.M. Bode, M.D and colleagues found that screening and decolonizing patients who are nasal carriers of S. aureus, combined with washing with chlorhexidine soap reduced the risk of SSIs by 58%.

From October 2005 through June 2007, Bode and colleagues screened 6771 patients on admission for nasal colonization of Staphylococcus aureus. Of these, positive nasal swabs were identified in 1251 patients. Of 917 of these patients enrolled in the intent-to-treat analysis, 808 (88.1%) underwent a surgical procedure.

All of the S aureus strains identified with PCR assay were susceptible to methicillin and mupirocin. In the mupirocin-chlorhexidine group, 17 (3.4%) of 504 patients developed S aureus infections vs 32 (7.7%) of 413 patients in the placebo group. Therefore, relative risk for infection was 0.42.

"The weight of evidence suggests that chlorhexidine–alcohol should replace povidone–iodine as the standard for preoperative surgical scrubs," Dr. Wenzel writes. "The use of intranasal mupirocin and chlorhexidine baths for carriers of S. aureus who have been identified preoperatively by means of a real-time [PCR] assay could be reserved primarily for patients who are undergoing cardiac surgery, all patients receiving an implant, and all immunosuppressed surgical candidates. Currently, the incremental value of preoperative baths with chlorhexidine alone for all surgical patients is unclear, but this relatively straightforward procedure could be examined critically in future studies."

Sources
Minimizing Surgical-Site Infections; N Engl J Med. 2010;362:9-17, 75-77; Richard P. Wenzel, M.D.
Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis; N Engl J Med 2010 Jan 7; 362:18; Darouiche RO et al.

Preventing surgical-site infections in nasal carriers of Staphylococcus aureus
; N Engl J Med 2010 Jan 7; 362:9; Bode LGM et al.
StopHospitalInfections.org

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