Abstract
BackgroundCutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times.MethodsUsing a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique.ResultsAerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported.ConclusionsPVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.
Highlights
The skin flora of patients is one of the most important factors in the pathogenesis of surgical site infections (SSI) [1,2,3,4]
PVP-IALC was significantly more effective than chlorhexidine gluconate (CHG)-ALC when applied for 2.5 min, at the sampling time immediately after application (Tables 1 and 2), but this was not the case for the prolonged application time of 30 min and not for any 3-h values
The results of our study demonstrate that both antiseptic compounds, CHG with alcohol (CHG-ALC) and PVP-I-ALC effectively decreased the aerobic skin flora at shoulder sites
Summary
The skin flora of patients is one of the most important factors in the pathogenesis of surgical site infections (SSI) [1,2,3,4]. Skin antisepsis constitutes an effective measure to reduce the numbers of microorganisms on Dörfel et al Antimicrob Resist Infect Control (2021) 10:17 skin It has been included as a key measure to prevent SSIs in recent international guidelines and recommendations [5,6,7]. Many comparisons in the literature consisted of unequal two-against-one comparisons, for example, CHG-ALC combinations against aqueous PVP-I, or of comparisons of antiseptics with unknown or inadequate active ingredient content [9, 10] Uncertainty surrounding these questions is reflected by differences between recommendations in recent major guidelines; while the US Centers for Disease Control and Prevention guideline recommends an alcohol-based antiseptic with either CHG or PVP-I [6], the World Health Organization guideline recommends CHG-ALC over PVP-I-ALC [5]. We compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times
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