What Skin Preparation Products Provide A Rapid Decrease In The Level Of Microorganisms
Rev Urol. 2009 Fall; xi(4): 190–195.
Pare Preparation for the Prevention of Surgical Site Infection: Which Agent Is All-time?
Abstract
Procedural and surgical site infections create difficult and circuitous clinical scenarios. A source for pathogens is oft thought to be the skin surface, making skin preparation at the time of the process critical. The most common pare preparation agents used today include products containing iodophors or chlorhexidine gluconate. Agents are further classified by whether they are aqueous-based or alcohol-based solutions. Traditional aqueous-based iodophors, such as povidone-iodine, are one of the few products that can be safely used on mucous membrane surfaces. Alcohol-based solutions are quick, sustained, and durable, with broader spectrum antimicrobial action. These agents seem platonic for longer open surgeries with the potential for irrigation or surgical spillage, such equally cystoprostatectomy, radical prostatectomy, and retroperitoneal lymph node dissection.
Primal words: Pare pathogens, Procedural and surgical site infection, Skin preparation solutions
Surgical site infection (SSI) complicates an estimated 5% of all clean-contaminated operations performed annually in US hospitals and accounts for the most common nosocomial infection in surgical patients.1 Patients who develop SSI have longer and costlier hospitalizations and are more than probable to spend time in an intensive care unit (ICU), are v times more than likely to exist readmitted, and are twice as likely to die.2
Recognizing this substantial morbidity and economic brunt, in 1999 the Centers for Disease Control (CDC) issued standardized guidelines for the prevention of surgical infections. These included making specific prove-based recommendations for modifying patient factors that may predispose to infection, for the use of antimicrobial prophylaxis, for optimizing sterility in the operating room, and for the use of antiseptic agents for skin training.
The option of which specific amanuensis to use for skin preparation was not addressed due to the diversity of sites and approaches in surgery, besides as the absence of data on SSI risk in well-controlled, operation-specific studies.1 Therefore, the choice of amanuensis should be based primarily on the surgeon'south knowledge of the product's efficacy, cost, and ease of use. Urologic surgeons have the additional challenge of choosing the best agent for the diversity of procedures that they perform, including intraperitoneal and extraperitoneal surgery; scrotal, perineal, and vaginal operations; endoscopy; and percutaneous renal surgery. Each of these operative sites has dissimilar endogenous flora, trunk contours, and skin types, all factors that influence the risk of SSI and, therefore, the all-time type of clarified peel agent to use. This article focuses on skin preparation for the prevention of SSI with an assessment of currently available clarified products and their application to urologic surgery.
History
The first use of an antiseptic pare amanuensis in surgery is credited to the English surgeon Joseph Lister (1827–1912). Prior to the mid-19th century, limb amputation was associated with an alarming 50% postoperative bloodshed from sepsis. Following Louis Pasteur's discovery that tissue decay was acquired by microscopic organisms, Lister theorized that the spread of these microbes through surgical wounds was responsible for death in the postoperative period. Lister began treating wounds with carbolic acrid (phenol) in an effort to foreclose tissue disuse and the resultant infectious complications. Equally a result, the incidence of surgical sepsis cruel dramatically, catalyzing the adoption of modern antiseptic techniques, including instrument sterilization, the use of surgical scrub and safe gloves, and sterile patient training.3
Mod Surgical Skin Training
The most common skin training agents used today include products containing iodophors or chlorhexidine gluconate (CHG). Agents are further classified by whether they are aqueous or alcohol-based solutions (Tabular array i).1
Table ane
Characteristics of Antiseptic Solutions
| Antiseptic | Mechanism of Action | Antimicrobial Coverage | Onset | Duration | Application | Examples |
| Aqueous-iodophor | Free iodine − protein, DNA harm | Excellent for gram + bacteria, good for gram −, fungi, virus, Mtb | Intermediate | 2 hoursxix | 2-stride scrub and paint | Betadine* Scrub Care† |
| Aqueous-CHG | Disrupts membranes | Splendid for gram +, good for gram − and virus, fair for mucus, poor for Mtb | Intermediate | vi hours20 | 2-step scrub and dry, repeat | Hibiclens‡ |
| Alcohol-iodophor | Denatures protein, free iodine − protein, Dna damage | Improved gram −, Mtb activity | Rapid | 48 hours (DuraPrep)11 96 hours (Prevail-FX)21 | 1-stride paint Dry time, minimum of 3 min on hairless surface | DuraPrep solution§ Prevail-FX† |
| Booze-CHG | Denatures protein, disrupts membranes | Improved gram −, Mtb, fungal activity | Rapid | 48 hours22,23 | Dry out site: 30-sec scrub Moist site: 2-min scrub Dry time, minimum of three min on hairless surface | ChloraPrep |
Aqueous-Based Solutions
Aqueous-based iodophors such as povidone-iodine (PVP-I) contain iodine complexed with a solubilizing amanuensis that allows for the release of free iodine when in solution. Iodine acts in an antiseptic fashion past destroying microbial proteins and Dna. Iodophor-containing products savor widespread employ considering of their wide-spectrum antimicrobial backdrop, efficacy, and prophylactic on nearly all skin surfaces in patients regardless of age. In the aqueous form, most commercially available iodophors require a two-stride application in a scrub-and-paint technique, and their activity is express by the amount of time the amanuensis is in contact with the skin.4 A 2d product, aqueous-based chlorhexidine gluconate (CHG), works by disrupting bacterial cell membranes. CHG has more sustained antimicrobial action and is more resistant to neutralization by claret products than the iodophors. CHG is applied in a like manner to PVP-I, but should non be used in the genital region. This agent has gained popularity as a manus-scrubbing and showering clarified prior to surgery, simply also continues to be used every bit a patient peel training agent.5
Booze-Based Solutions
Ethyl and isopropyl booze are two of the virtually constructive antiseptic agents bachelor. When used alone, booze is fast and short acting, has broad-spectrum antimicrobial activeness, and is relatively cheap.1 Booze-based solutions that contain CHG or iodophors have sustained and durable antimicrobial activity that lasts long after alcohol evaporation.6 Considering alcohol dries on exposed skin within moments of application, these can be applied with a 1-step training as opposed to a scrub-and-paint technique.
A limitation to the use of alcohol in the operating room is its flammability on skin surfaces prior to evaporation. In that location take been a few reports of operating room fires originating from alcohol-based skin preparation resulting in significant injury to patients and staff.7 Flammability can be avoided by allowing skin to completely dry and avoiding grooming of areas with excessive body hair that can delay alcohol vaporization.
Additionally, alcohol-based solutions should not be applied to mucous membranes and therefore take limited utility every bit clarified agents prior to transurethral or transvaginal surgery. Nevertheless, combination solutions with alcohol and CHG or iodophors accept gained popularity among general, cardiac, and orthopedic surgeons and may have boosted utility in certain urologic procedures. Recent studies propose that these products may have greater efficacy, easier application, improved durability, and a superior cost contour when compared with traditional aqueous-based solutions.
I such production, 3M™ DuraPrep™ Surgical Solution (Iodine Povacrylex [0.vii% available iodine] and Isopropyl Alcohol, 74% due west/w) Patient Preoperative Pare Preparation (3M Wellness Care, St. Paul, MN), is an antiseptic skin solution that contains iodine povacrylex and isopropyl alcohol. It is practical in i step, has a dry fourth dimension of a minimum of 3 minutes on hairless skin, leaves a water-insoluble film on the skin surface that maintains antimicrobial activeness for up to 48 hours, and resists wash-off by saline and blood products (Figure 1). In vitro studies take demonstrated that DuraPrep solution is constructive against a wide range of microorganisms, including those most commonly encountered in genitourinary (GU) surgery, including gram-negative rods, Staphylococcus species, and Enterococcus, as well as multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and vancomycin-resistant enterococci (VRE).8 Furthermore, DuraPrep solution accomplishes a 6-fold bacterial log reduction within 1 minute of contact with a greater percentage release of gratis iodine when compared with the leading aqueous iodophors.eight
Application of DuraPrep™ Surgical Solution (3M Health Care, St. Paul, MN). Adapted with permission from 3M Health Care.
Another potential reward of this product is its durability in the surgical environment. In a prospective, randomized surgical simulation study, DuraPrep solution demonstrated ameliorate antimicrobial activeness after saline soak when compared with the leading CHG alcohol-based solution (ChloraPrep®; CareFusion, Inc., Leawood, KS), suggesting that it is particularly suitable for use in "wet" surgical environments (Effigy 2).9 Another unique feature of DuraPrep solution is that it enhances adhesion between surgical drapes and the prepared skin surface, theoretically limiting the spread of organisms onto the surgical field. In a randomized, prospective study comparing curtain adhesion in patients undergoing total joint replacement, patients prepared with DuraPrep solution had significantly less area of drape lift than those prepared with PVP-I, 1.5 cmtwo versus 9.9 cmtwo, respectively (P < .0001).10 This agglutinative holding may be particularly advantageous for long, open procedures with the potential for fluid spillage on the surgical field, such as cystoprostatectomy, radical prostatectomy, and retroperitoneal lymph node dissection (RPLND).
Bacterial log reduction after saline challenge. *P < .003 for soak status. Reproduced with permission from Stahl JB et al.9
Although there accept been no studies in the urologic literature addressing the effect of this product on SSI, clinical studies have been conducted in general, cardiac, and orthopedic surgery, as well as in patients undergoing anesthesia procedures. In a prospective, randomized study of full general surgery patients undergoing operations iii hours or longer, the use of DuraPrep solution resulted in a 3-fold decrease in SSI when compared with tincture of iodine.11 Another written report of 3209 general surgical procedures compared the employ of 3 skin preparations: a povidone-iodine scrub-paint combination (Betadine®, Purdue Products, LP, Stamford, CT) (with an isopropyl alcohol application between the steps), ChloraPrep, and DuraPrep solution.12 This study employed a sequential implementation design, and each agent was used for a half-dozen-month menses for all full general surgery cases. PSSIs were tracked for xxx days.
DuraPrep solution was associated with the everyman infection rate (3.9%, compared with 6.4% for Betadine and 7.1% for ChloraPrep [P = .002]). In subgroup analysis, no divergence in outcomes was seen between patients prepared with Betadine/alcohol and those prepared with DuraPrep solution, but patients in both these groups had significantly lower PSSI rates compared with patients prepared with ChloraPrep (four.8% vs eight.2% [P = .001]).
In the cardiac literature, a comparison of DuraPrep solution with the leading PVP-I in patients at high take chances for SSI undergoing open up heart surgery, four of 101 patients in the DuraPrep solution group developed wound infections compared with 14 of 108 in the PVP-I group.13 At another center, the introduction of DuraPrep solution in a cardiac surgery service was associated with a more 50% reduction in overall SSI, sternal wound infection, and repeat surgical intervention for infection.14
In a study of patients undergoing epidural catheter placement on an obstetrics ward, DuraPrep solution was prospectively compared with PVP-I. The DuraPrep solution group showed a significant subtract in the number of positive skin cultures obtained immediately after disinfection and immediately prior to catheter removal. In addition, bacteria was cultured from 2 epidural catheter tips in patients treated with DuraPrep solution compared with xiii positive cultures from catheter tips in the PVP-I group.15 This finding suggests that DuraPrep solution may be particularly suitable for percutaneous renal access procedures where catheters are oftentimes left in place postoperatively, thus serving equally a potential entry bespeak for infection.
Finally, a prospective clinical study in the orthopedic literature suggests that alcohol-based solutions with iodophor or CHG may have improved efficacy at reducing bacterial counts in "moist" surgical sites or body regions with increased endogenous bacterial colonization. I hundred twenty-five patients undergoing foot and ankle surgery were randomized to receive preparation with 3M™ DuraPrep™ Surgical Solution (Iodine Povacrylex [0.seven% bachelor iodine] and Isopropyl Alcohol, 74% w/west) Patient Preoperative Skin Preparation, ChloraPrep, or Techni-Care® Surgical Scrub (Care-Tech Laboratories, Inc., St. Louis, MO). The sites treated with booze-based solutions had on boilerplate a 50% reduction in positive cultures compared with those treated with traditional clarified agents. Overall, ChloraPrep performed two-fold better than DuraPrep solution, but the findings of this written report have been criticized because no neutralization agent was used prior to obtaining cultures from the surface of the treated areas. Because ChloraPrep is a not-film forming antiseptic, without the use of a neutralizer, information technology is likely that in this group, sampling contaminated with antiseptic led to ongoing bacterial death and exaggerated efficacy. Additionally, no patients developed SSI in the DuraPrep solution group.16
These findings can exist generalized to other "moist" surgical sites, suggesting that alcohol-based solutions may be efficacious for use in groin, scrotal, or perineal urologic surgery, particularly for implantation of foreign devices such equally penile prostheses or bogus urinary sphincters where minimizing bacterial counts is critical.
In improver to an analysis of efficacy, ease of use, toll, and user satisfaction are important considerations when choosing a pare training agent. In a prospective comparing of alcohol-based iodophors with traditional PVP-I preparation, the booze-based solutions had shorter awarding and drying times. Taking into consideration operating room time and product expenses, the alcohol-containing products had lower overall costs.17 Other studies have confirmed this finding, showing that the use of DuraPrep solution has potential savings of $78 per patient (Tabular array 2).18 Despite these advantages, operating room personnel preferred PVP-I scrub-and-paint to the alcohol preparations, citing concern over flammability as the most important overall deciding factor. Familiarity with PVP-I scrub-and-pigment, yet, may have introduced bias into the assessment of user satisfaction considering personnel had trivial to no feel with booze-based solutions prior to the study.xix With safety use and proper instruction, alcohol-based antiseptics may relieve valuable time and operating room resource.
Table two
Comparison of Antiseptic Products
| OR Durability | Incidence of Surgical Site Infection | Ease of Use | |||||
| Antiseptic | Soak | Mantle lift | General | General | Cardiac | Application | Cost |
| Stahl et al9 Northward = 36 P = .006 | Jacobson et al10 N = 171 P < .0001 | Pinheiro et alxi N = 214 P < .05 | Swenson et al12 Northward = 3209* P < .002 | Segal and Anderson13 N = 209 P = .02 | Armstrong et al17 N = 25 | Roberts et alxviii N = 200 P = .0001 | |
| DuraPrep solution† | 3.seven bacterial log reduction | one.5 cm2 | 4.8% | 3.ix% | 4% | 82.viii sec With drape application | $56.96 |
| Tincture of iodine | – | – | xiv.7% | – | – | – | |
| Prevail‡ | – | – | – | – | 42.2 sec | – | |
| ChloraPrep§ | 3.2 bacterial log reduction | – | – | 7.one% | – | – | – |
| PVP-I | – | 9.ix cmtwo | – | 6.iv% | 13% | 228 sec | $135.28 |
Conclusion
The goal of preoperative skin training is to reduce the incidence of SSI in a safe, convenient, and price-effective style. Because urologists perform a breadth of different operations accessing numerous surgical sites, a standard antiseptic agent is unlikely to be uniformly optimal. Traditional aqueous-based iodophors such equally PVP-I are ideal for transvaginal and transurethral surgery and are one of the few products that tin can be safely used on mucous membrane surfaces. Likewise, alcoholbased solutions such every bit DuraPrep solution are quick, sustained, and durable with broader spectrum antimicrobial activity. These seem ideal for longer open surgeries with the potential for irrigation or surgical spillage, for percutaneous procedures with indwelling catheters, and for prosthesis implantation when minimizing skin colony counts is critical to forestall hardware infection. Because alcohol is flammable, when using these products intendance must exist taken to allow adequate drying time and to remove excessive pilus from the prepared field that may delay alcohol vaporization.
Footnotes
Dr. Micah Fifty. Hemani and Dr. Herbert Lepor take been reimbursed past 3M Visitor for their contributions.
References
ane. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Informational Committee. Infect Control Hosp Epidemiol. 1999;20:250–278. quiz 279–280. [PubMed] [Google Scholar]
2. Kirkland KB, Briggs JP, Trivette SL, et al. The bear upon of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and actress costs. Infect Control Hosp Epidemiol. 1999;20:725–730. [PubMed] [Google Scholar]
3. Newsom BD. Surgical wound infections: a historical review. Int J Infect Control. 2008;4:ane. [Google Scholar]
4. Digison MB. A review of antiseptic agents for pre-operative skin preparation. Plast Surg Nurs. 2007;27:185–189. quiz 190–191. [PubMed] [Google Scholar]
5. Hibbard JS. Analyses comparison the antimicrobial activity and safety of electric current antiseptic agents: a review. J Infus Nurs. 2005;28:194–207. [PubMed] [Google Scholar]
6. Brook WX. After 2000 years, alcohol yet excels. Infections in Surgery. 1985 [Google Scholar]
7. Weber SM, Hargunani CA, Wax MK. DuraPrep and the risk of burn during tracheostomy. Head Neck. 2006;28:649–652. [PubMed] [Google Scholar]
viii. Data on file. St. Paul, MN;: 3M Health Care; [Google Scholar]
9. Stahl JB, Morse D, Parks PJ. Resistance of antimicrobial skin preparations to saline rinse using a seeded bacteria model. Am J Infect Control. 2007;35:367–373. [PubMed] [Google Scholar]
x. Jacobson C, Osmon DR, Hanssen A, et al. Prevention of wound contamination using DuraPrep Solution plus loban two drapes. Clin Orthop Relat Res. 2005;439:32–37. [PubMed] [Google Scholar]
11. Pinheiro SM, Couto BR, Pimenta JP, et al. Effects of iodophor skin training in reducing surgical site infection. Abstract presented at: 14th Almanac Meeting of the Social club for Healthcare Epidemiology of America; April 17–20, 2004; Philadelphia, PA. Abstract 329. [Google Scholar]
12. Swenson BR, Hedrick TL, Metzger R, et al. Furnishings of preoperative skin preparation on postoperative wound infection rates: a prospective report of 3 pare preparation protocols. Infect Control Hosp Epidemiol. 2009;30:964–971. [PMC free commodity] [PubMed] [Google Scholar]
13. Segal CG, Anderson JJ. Preoperative peel preparation of cardiac patients. AORN J. 2002;76:821–828. [PubMed] [Google Scholar]
14. Squier C, Miller T, DiLucia B, et al. Cardiac bypass surgery: intervention to subtract surgical site infections. Abstract presented at: fourth Decennial International conference on Nosocomial and Health Care-Associated Infections in conjunction with the tenth Annual Meeting of the Society for Healthcare Epidemiology of America; March five–9, 2009; Atlanta, GA. [Google Scholar]
15. Birnbach DJ, Meadows W, Stein DJ, et al. Comparison of povidone iodine and DuraPrep, an iodophor-in-isopropyl alcohol solution, for pare disinfection prior to epidural catheter insertion in parturients. Anesthesiology. 2003;98:164–169. [PubMed] [Google Scholar]
16. Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in human foot and talocrural joint surgery. J Bone Joint Surg (Am) 2005;87:980–985. [PubMed] [Google Scholar]
17. Armstrong EP, Patrick KL, Erstad BL. Comparing of preoperative skin grooming products. Pharmacotherapy. 2001;21:345–350. [PubMed] [Google Scholar]
eighteen. Roberts AJ, Wilcox Grand, Devineni R, et al. Pare preparations in CABG surgery: a prospective randomized trial. Comp Surg. 1995;14:741–748. [Google Scholar]
xix. Khera SY, Kostyal DA, Deshmukh N. A comparison of chlorhexidine and povidone-iodine pare preparation for surgical operations. Curr Surg. 1999;56:341–343. [Google Scholar]
20. Information on file. Norcross, GA: Mölnlycke Wellness Care, Inc.; [Google Scholar]
21. Information on file. Dublin, OH: Cardinal Health; [Google Scholar]
22. Garcia R, Mulberry G, Brady A, Hibbard JS. Comparison of ChloraPrep and Betadine as preoperative peel preparation antiseptics. Poster presented at: 40th Annual Meeting of the Infectious disease Society of America; Oct 25, 2002; Chicago, IL. [Google Scholar]
23. Data on file. San Diego, CA: CareFusion, Inc.; [Google Scholar]
Articles from Reviews in Urology are provided here courtesy of MedReviews, LLC
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809986/
Posted by: tuttlespeliveral.blogspot.com
0 Response to "What Skin Preparation Products Provide A Rapid Decrease In The Level Of Microorganisms"
Post a Comment