Surgical Preparation Solutions Research Articles

Does Adding Hydrogen Peroxide to Chlorhexidine Gluconate Increase the Effectiveness of Skin Preparation in Reducing Cutaneous Cutibacterium Levels? A Randomized Controlled Trial

IntroductionShoulder periprosthetic joint infection (PJI) is most commonly caused by Cutibacterium. Effective removal of these bacteria from the skin is difficult because Cutibacterium live protected in the dermal sebaceous glands beneath the skin surface to which surgical preparation solutions, such as chlorhexidine gluconate (CHG), are applied. There is conflicting evidence on the additional benefit of using hydrogen peroxide (H2O2) as an adjunct to CHG in eliminating Cutibacterium from the skin. A previous study demonstrated that after CHG skin preparation, repopulation of Cutibacterium from sebaceous glands onto the skin surface occurs in 90% of shoulders by 60 minutes after application. The objective of this randomized controlled study was to determine the effectiveness of adding H2O2 to CHG in reducing skin Cutibacterium. MethodsEighteen male volunteers (36 shoulders) were recruited for this study. The two shoulders of each volunteer were randomized to receive the control preparation (“CHG-only” – 2% CHG in 70% isopropyl alcohol [ISA] alone) or the study preparation (“H2O2+CHG” – 3% H2O2 followed by 2% CHG in 70% ISA). Skin swabs were taken from each shoulder prior to skin preparation and again at 60 minutes after preparation. Swabs were cultured for Cutibacterium and observed for 14 days. Cutibacterium skin load was reported using a semi-quantitative system based on the number of quadrants growing on the culture plate. ResultsPrior to skin preparation, 100% of the CHG-only shoulders and 100% of the H2O2+CHG shoulders had positive skin surface cultures for Cutibacterium. Repopulation of Cutibacterium on the skin at 60 minutes occurred in 78% of CHG-only and 78% of H2O2+CHG shoulders (p=1.00). Reduction of Cutibacterium skin levels occurred in 56% of CHG-only and 61% of H2O2+CHG shoulders (p=0.735). Cutibacterium levels were significantly decreased from before skin preparation to 60 minutes after preparation in both the CHG-only (2.1 ± 0.8 to 1.3 ± 0.9, p=0.003) and the H2O2+CHG groups (2.2 ± 0.7 to 1.4 ± 0.9, p<0.001). Substantial skin surface levels of Cutibacterium were present at 60 minutes after both preparations. ConclusionsIn this randomized controlled study, there was no additional benefit of using hydrogen peroxide as an adjunct to chlorhexidine gluconate skin preparation in the reduction of cutaneous Cutibacterium levels. Neither preparation was able to eliminate repopulation of Cutibacterium on the skin surface from the dermal sebaceous glands.

Pragmatic design and inclusion of patient-partner representatives improves participant experience in clinical research.

Patient engagement in the design and implementation of clinical trials is necessary to ensure that the research is relevant and responsive to patients. The PREP-IT trials, which include 2 pragmatic trials that evaluate different surgical preparation solutions in orthopaedic trauma patients, followed the patient-centered outcomes research (PCOR) methodology throughout the design, implementation, and conduct. We conducted a substudy within the PREP-IT trials to explore participants' experiences with trial participation. At the final follow-up visit (12 months after their fracture), patients participating in the PREP-IT trials were invited to participate in the substudy. After providing informed consent, participants completed a questionnaire that asked about their experience and satisfaction with participating in the PREP-IT trials. Descriptive statistics are used to report the findings. Four hundred two participants participated in the substudy. Most participants (394 [98%]) reported a positive experience, and 376 (94%) participants felt their contributions were appreciated. The primary reasons for participation were helping future patients with fracture (279 [69%]) and to contribute to science (223 [56%]). Two hundred seventeen (46%) participants indicated that their decision to participate was influenced by the minimal time commitment. Most participants reported a positive experience with participating in the PREP-IT trials. Altruism was the largest motivator for participating in this research. Approximately half of the participants indicated that the pragmatic, low-participant burden design of the trial influenced their decision to participate. Meaningful patient engagement, a pragmatic, and low-burden protocol led to high levels of participant satisfaction.

Correction to: “Efficacy of surgical skin preparation solutions in hip arthroplasty: a prospective randomized trial”

C JS has been made aware that the article, “Efficacy of surgical skin preparation solutions in hip arthroplasty: a prospective randomized trial,” published on November 16, 2022,[1][1] should have included the following acknowledgement: The authors thank Lori Moon for assistance with participant

Comparing Infection Rates from Using Different Surgical Preparation Solutions and Techniques in Foot &amp; Ankle Elective Surgery

Category:OtherIntroduction/Purpose:Surgical site infection (SSI) after Foot & Ankle surgery ranges from 1.2% to 13.2%, higher than any other elective orthopaedic procedure. Infection is of concern for the patient and expensive for the healthcare system. SSI is multifactorial and can be divided into host-related and perioperative factors. Skin preparation is one of the key peri-operative factors in reducing SSI. The current literature supports a combined chlorhexidine and alcohol preparation technique, although there is some conflicting evidence. Most studies to date have used proxy outcomes such as growth from swabs shortly after skin preparation. There are no large scale studies which have looked at definitive clinical outcomes such as the rate of postoperative SSI.Methods:A retrospective review of data was undertaken for two longitudinal cohorts which were using two different skin preparation solutions and techniques due to a change in hospital protocol. Each cohort was continuous and derived from the same overall populationIn cohort 1, Povidine-Iodine (Betadinetm) followed by Alcoholic Chlorhexidine was used on swabs (Double prep group). In cohort 2, 2 Alcoholic Chlorhexidine was used in a prep stick applicator. Standard criteria for diagnosing surgical site infection were used. All open injuries, procedures for ongoing infection, amputations for osteomyelitis /diabetic foot and COVID- 19 positive cases were excluded.Results:After applying standard exclusion criteria, 919 elective F&A procedures in the Double prep group and 491 procedures were included for the Single prep groupAs these were continuous longitudinal cohorts of large scale from the same population, there is a justifiable presumption of group matchingIn cohort 1 there were 15 superficial infections (1.6%) and 3 deep (0.3%). In cohort 2 there were 18 superfical infections (3.6%) and 1 deep (0.3%). The total infections in cohort 1 were 18 (2%) and 19 in cohort 2 (3.9%)There was an increase in superficial, and therefore total infection rates, in the single prep group compared to the double prep group. These increases were statistically significant; p <0.05 with regards to superficial infection and total infection rates in the single prep group.Conclusion:Double skin preparation, with Povidone-Iodine followed by alcoholic Chlorhexadine, statistically significantly decreases foot and ankle surgical infection rates as compared to a single alcoholic chlorhexidine skin preparation

Small animal Review

Summary: This month's Small Animal Review summarises studies on the effect of surgical preparation solutions on body temperature in cats, the persistence of leptospires in canine urine following treatment outcomes of oesophageal stricture.

Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery.

Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.

Large variations in the practice patterns of surgical antiseptic preparation solutions in patients with open and closed extremity fractures: a cross-sectional survey

BackgroundSurgically-managed fractures, particularly open fractures, are associated with high rates of surgical site infections (SSIs). To reduce the risk of an SSI, orthopaedic surgeons routinely clean open fracture wounds in the emergency department (ED) and then apply a bandage to the open wound. Prior to the surgical incision, it is standard practice to prepare the fracture region with an antiseptic skin solution as an additional SSI prevention strategy. Multiple antiseptic solutions are available.ObjectivesTo explore the variation in practice patterns among orthopaedic surgeons regarding antiseptic solution use in the ED and antiseptic preparatory techniques for fracture surgery.MethodsWe developed a 27-item survey and surveyed members of several orthopaedic associations.ResultsTwo hundred and-ten surveys were completed. 71.0% of respondents irrigate the open wound and skin in the ED, primarily with saline alone (59.7%) or iodine-based solutions (32.9%). 90.5% of responders indicated that they dress the open wound in the ED, with 41.0% applying a saline-soaked bandage and 33.7% applying an iodine-soaked dressing (33.7%). In their surgical preparation of open fractures, 41.0% of respondents used an iodine-based solution, 26.7% used a chlorhexidine gluconate (CHG)-based solution, and 31.4% used a combination of the two. In closed fractures, 43.8% of respondents used a CHG-based solution, 28.1% used an iodine-based solution, and 27.1% used a combination. Despite theoretical concerns about the use of alcohol in open wounds, 51.4% used alcohol-based solutions or alcohol alone during skin preparation of open fractures.ConclusionsA lack of consensus exists regarding use of antiseptic surgical preparation solutions for fractures. High-quality clinical research is needed to assess the effectiveness of different surgical antiseptic preparation solutions on patient outcomes in fracture populations.

Propionibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study

To examine the contamination rate of the anchor-suture and to determine the efficacy of 2 different surgical skin preparation solutions with or without a plastic adhesive drape from suture contamination in arthroscopic rotator cuff repair. A prospective randomized study was undertaken to evaluate 126 consecutive patients undergoing arthroscopic rotator cuff repair. Each shoulder was prepared with one of 2 randomly selected solutions according to an assigned envelope that indicated the procedure to be used: chlorhexidine-alcohol (1% chlorhexidine gluconate and 70% isopropyl alcohol) or povidone-iodine. Then, each group was further divided according to the usage of a plastic drape. The first cut-tails of the anchor-suture after cuff fixation were submitted to aerobic and anaerobic cultures. The overall rate of Propionibacterium acnes-positive cultures was 47% (14 of 31 cases) in the povidone-iodine group, 33% (11 of 33 cases) in the povidone-iodine with a drape group, 33% (10 of 30 cases) in the chlorhexidine-alcohol group, and 9.3% (3 of 32 cases) in the chlorhexidine-alcohol with a drape group. The positive culture rate in the chlorhexidine-alcohol with a drape group was lower than that in the povidone-iodine group (relative risk, 0.2; 95% confidence interval: 0.064-0.63; number needed to treat, 2.7; P < .0001). Coagulase-negative staphylococci were isolated in the povidone-iodine with a drape (1 case) and chlorhexidine-alcohol with a drape group (2 cases). No other bacteria were isolated, and no infections occurred in any of the patients treated in this study during the minimum 12-month follow-up period. Chlorhexidine-alcohol solution with an adhesive plastic drape was more effective than chlorhexidine-alcohol without a plastic drape and povidone-iodine with/without a plastic drape in eliminating P acnes suture contamination. However, the usage of a plastic drape slightly increased the risk of coagulase-negative Staphylococcus proliferation. Level I, therapeutic, prospective, randomized trial.

Propionibacterium in Shoulder Arthroplasty: What We Think We Know Today.

➤ Propionibacterium is a slow-growing gram-positive rod that is part of the normal skin microbiome but can be found on culture of specimens from a large number of patients having revision shoulder arthroplasty performed for pain, stiffness, and component loosening. ➤ Propionibacterium infections do not present with obvious signs of infection, such as swelling, erythema, drainage, or tenderness, but rather are of the so-called stealth type, presenting with unexplained pain, stiffness, or component loosening months to years after the index arthroplasty. ➤ Not all propionibacteria are the same: certain subtypes of Propionibacterium are enriched with virulence factors that may enhance deep infection. ➤ Because propionibacteria typically reside in the pilosebaceous glands of the oily skin of the chest and back, standard surgical skin preparation solutions and even perioperative intravenous antibiotics are often inadequate at sterilizing the incision site; therefore, other prophylactic measures such as meticulous implant handling to avoid contact with dermal structures need to be considered. ➤ Recovery of Propionibacterium from the surgical wounds requires that multiple specimens for culture be taken from different areas of the shoulder to reduce sampling error, and cultures should be held for two weeks on multiple culture media. ➤ Future research efforts can be focused on reducing the risk of implant infection and point-of-care methods for identifying Propionibacterium infections.

Single vs Repeat Surgical Skin Preparations for Reducing Surgical Site Infection After Total Joint Arthroplasty: A Prospective, Randomized, Double-Blinded Study

BackgroundPreventing surgical site infection (SSI) after total joint arthroplasty (TJA) is a high priority and is partly linked to the efficacy of surgical site preparation solutions (SPSs) in reducing the number of pathogens on the skin before incision. The aim of this study is to investigate the effectiveness of SRS reapplication after draping to reduce the incidence of SSI after TJA. MethodsSix hundred patients undergoing primary TJA between 2010 and 2011 at a single institution were recruited and randomly assigned to one of 2 groups. The patients in the intervention group (n = 300) received SPS that included alcohol and povidone-iodine before draping and an additional SPS by iodine povacrylex and isopropyl alcohol before application of the final adhesive drape, whereas the patients in the control group (n = 300) received a single SPS with alcohol and povidone-iodine before draping. Randomization was performed by an opaque envelope, and the rates of SSI and blistering were compared between groups. ResultsFive seventy-seven patients completed the study and were included in the final analysis. There was a significant reduction in the incidence of superficial SSI for the intervention group (1.8%, 5 of 283) compared to the control group (6.5%, 19 of 294, P = .02). There were 2 (0.7%, 2 of 294) deep incisional SSIs in the control group, and 2 (0.7%, 2 of 283) organ-space SSIs in the intervention group (P = 1.00). In addition, skin blistering was lower in the intervention group (3.5%, 10 of 283) vs the control group (6.5%, 19 of 294), but this difference also did not reach statistical significance (P = .13). ConclusionReapplication of an SPS after draping and before the application of iodophor-impregnated incisive draping resulted in a significant reduction in the rate of SSI in patients undergoing elective TJA.

Comparison of the antimicrobial efficacy of chlorhexidine gluconate and povidone iodine as preoperative surgical preparation solutions in cattle under field conditions

Antimicrobial substances are used in the preoperative period to reduce the number of resident skin flora and prevent surgical wound infection. Most standing abdominal surgeries in cattle are classified as clean contaminated and are performed on potentially immune-compromised cattle in a contaminated area. Thus, the antiseptic used must quickly reduce the number of microbes present while at the same time preventing bacterial recolonization following the procedure. This can be particularly difficult in field conditions where many environmental contaminants cannot be controlled by the surgeon. Environmental conditions are a major contributing factor in determining the efficacy and residual effects of antiseptic agents. Therefore, a preparation procedure with a high percentage of bacterial reduction and prolonged residual activity would prove favorable in the surgical management of cattle in a field setting. The few studies that have been completed on surgical site preparation in cattle have either been conducted in a sterile hospital surgical suite or only using 1 product in 2 different manners in a field situation. The purpose of this study was to document the comparative efficacy of a standard iodophor and alcohol preparation and a chlorhexidine and alcohol preparation in cattle under field conditions.

The Efficacy of Surgical Preparation Solutions in Hand Surgery: Level 1 Evidence

Skin antisepsis prior to incision is a cornerstone of surgical standard of care. The ideal preoperative skin preparation solutions have been previously studied for spine, shoulder, and foot surgery. However, the normal flora of the hand may differ from these surgical sites and the ideal preparation solution has not been determined. The purpose of this study is to determine the effectiveness of three commonly used surgical preparation solutions (Chloraprep, Duraprep, and Betadine) in eliminating bacteria from the skin prior to incision.

Perioperative Skin Preparation

Liaison: Anthony T Tokarski BS Leaders: David Blaha MD (US), Michael A. Mont MD (US), Parag Sancheti MS, DNB, MCh (International) Delegates: Lyssette Cardona MD, MPH, MHA, AAHIVS, FIDSA, Gilberto Lara Cotacio MD, Mark Froimson MD, Bhaveen Kapadia MD, James Kuderna MD, PhD, Juan Carlos Lopez MD, Wadih Y Matar MD, MSc, FRCSC, Joseph McCarthy MD, Rhidian Morgan-Jones MB BCh, FRCS, Michael Patzakis MD, Ran Schwarzkopf MD, Gholam Hossain Shahcheraghi MD, Xifu Shang MD, Petri Virolainen MD, PhD, Montri D. Wongworawat MD, Adolph Yates Jr, MD

Efficacy of Surgical Preparation Solutions in Lumbar Spine Surgery

Postoperative spinal wound infections are relatively common and are often associated with increased morbidity and poor long-term patient outcomes. The purposes of this study were to identify the common bacterial flora on the skin overlying the lumbar spine and evaluate the efficacy of readily available skin-preparation solutions in the elimination of bacterial pathogens from the surgical site following skin preparation. A prospective randomized study was undertaken to evaluate 100 consecutive patients undergoing elective lumbar spine surgery. At the time of surgery, the patients were randomized to be treated with one of two widely used, and Food and Drug Administration (FDA)-approved, surgical skin-preparation solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) or DuraPrep (0.7% available iodine and 74% isopropyl alcohol). Specimens for aerobic and anaerobic cultures were obtained prior to skin preparation (pre-preparation), after skin preparation (post-preparation), and after wound closure (post-closure). A validated neutralization solution was used for each culture to ensure that the antimicrobial activity was stopped immediately after the sample was taken. Positive cultures and specific bacterial pathogens were recorded. Coagulase-negative Staphylococcus, Propionibacterium acnes, and Corynebacterium were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures prior to skin preparation was 82%. The overall rate of positive cultures after skin preparation was 0% (zero of fifty) in the ChloraPrep group and 6% (three of fifty) in the DuraPrep group (p = 0.24, 95% confidence interval [CI] = 0.006 to 0.085). There was an increase in positive cultures after wound closure, but there was no difference between the ChloraPrep group (34%, seventeen of fifty) and the DuraPrep group (32%, sixteen of fifty) (p = 0.22, 95% CI = 0.284 to 0.483). Body mass index (BMI), duration of surgery, and estimated blood loss did not a show significant association with post-closure positive culture results. ChloraPrep and DuraPrep are equally effective skin-preparation solutions for eradication of common bacterial pathogens on the skin overlying the lumbar spine.

Pre-Application Evaporation of Surgical Preparation Solutions: Does It Matter?

Introduction: Surgical site infections (SSIs) remain the most common health care associated infections in the surgical population. Preoperative surgical preparation solutions containing alcohol are believed to be best at eradicating skin microorganisms. The efficacy of alcohol is concentration dependant, with a concentration of greater than 60% most bactericidal. Surgical antisepsis guidelines do not stipulate how long alcoholic preparation solutions can be left out prior to use. Method: 30 ml of Alcoholic Iodine (Iodine 1% in Alcohol 70% (v/v)) and Alcoholic Chlorhexidine (Chlorhex-idine 2% in Alcohol 70% (v/v)) were left to stand in gallipots in an operating theatre equipped with laminar flow. Sam-ples were taken at 0, 30, 60 and 120 minutes and the alcohol content was analyzed. The experiment was repeated 3 times for each time interval. Results: The Alcoholic Iodine group demonstrated significant decrease in alcohol concen-tration, from a mean of 76% (SD 3.6) to a mean of 37.7% (SD 2.9) in only 30 minutes. This effect was sustained, reaching a mean concentration of 26% (SD 2.9) alcohol at 120 minutes. The Alcoholic Chlorhexidine group did not exhibit the same degree of concentration drop, the concentration dropped marginally to 71.5% (SD 2.7) at 120 minutes from 83.4% (SD 0.4). Conclusion: Alcoholic Iodine exhibits significant evaporation under operating room conditions after 30 minutes. Alcoholic Chlorhexidine does not appear to undergo similar losses in concentration. We recommend that alcoholic surgical preparation solutions must be poured immediately prior to use, and must be discarded if left un-covered for more than a few minutes.

A patient who was burned in the operative field: a case report

Operating room fires occur very rarely. Nevertheless, a disaster can complicate almost any kind of surgery. The majority of operating room fires result from the use of alcohol- based surgical preparation solutions, electro-surgical equipment, or flammable drapes in an oxygen-rich environment. We report a patient with an ovarian cyst and uterine myomas who suffered a flame burn while undergoing gynecological surgery.

Efficacy of Surgical Preparation Solutions in Shoulder Surgery

Efficacy of Surgical Preparation Solutions in Shoulder Surgery

Efficacy of Surgical Preparation Solutions in Shoulder Surgery

Deep infection following shoulder surgery is a rare but devastating problem. The use of an effective skin-preparation solution may be an important step in preventing infection. The purposes of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder. A prospective study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution. Each shoulder was prepared with one of three randomly selected solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodophor and 74% isopropyl alcohol), or povidone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint). Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients, to determine the native bacteria around the shoulder, and following skin preparation for all patients. Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures was 31% in the povidone-iodine group, 19% in the DuraPrep group, and 7% in the ChloraPrep group. The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group (p < 0.0001) and the DuraPrep group (p = 0.01). ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region (p < 0.001 for both). No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region. No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up. ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region. Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder.

Surgical Preparation Solutions and Preoperative Skin Disinfection

Surgical Preparation Solutions and Preoperative Skin Disinfection

Efficacy of Surgical Preparation Solutions in Foot and Ankle Surgery

To The Editor: I am writing to point out two limitations not mentioned in the study presented in your article, “Efficacy of Surgical Preparation Solutions in Foot and Ankle Surgery” (2005;87:980-5), by Ostrander et al. No neutralizing ingredient(s) (neutralizer) was used in the sampling method, either on the swab or in the transport or culture media. American Society for Testing and Materials (ASTM) method E1054-02 recommends adding appropriate neutralizers to the solution …