Running head: SURGICAL SITE INFECTION PREVENTION
Evidence Based Practice Regarding Chlorhexidine Use to Prevent Surgical Site Infection
Cindy Magirl, Eric Nelson, Tennille Sassano, Jennifer Vicarie
Ferris State University
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Abstract
Surgical site infections (SSIs) play a major role in post- operative complications. SSIs lead to
negative patient outcomes and have a negative impact on a healthcare organizations financial
status. An effective strategy to help prevent SSIs is the use of chlorhexidine gluconate (CHG)
pre-operatively and intra operatively. The studies reviewed for this paper have shown a decrease
in SSIs with the use of CHG. The evidence supports the use of CHG pre-operative and intra
operatively to prevent surgical site infections.
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Evidence Based Practice Regarding Chlorhexidine Use to Prevent Surgical Site Infection
Many different surgical preparations have been used over the years. There is much
literature regarding the use of Chlorhexidine for surgical preparation and preventing surgical site
infections (SSIs). Surgical site infections cost hospitals millions of dollars each year. The
question is how does Chlorhexidine compare to other surgical preparations?
The following four articles have been reviewed and summarized discussing the use of
Chlorhexidine and reducing the risk for SSI.
Article One
In the article “Evidence for Using Chlorhexidine Gluconate Preoperative Cleansing to Reduce
the Risk of Surgical Site Infections”, Edmiston, Okoli, Graham, Sinski, and Seabrook (2012),
review several different studies, evaluating the evidence for the use of Chlorhexidine gluconate
as an effective pre-surgical antiseptic bathing practice.
Annually, the amount of surgical site infections (SSIs) in the United States increases the
length of hospital stays resulting in more than $1.6 billion in hospital charges. In an attempt to
decrease these SSIs, processes have been implemented in several institutions that involve the
patient to do a pre-surgical antiseptic cleansing prior to coming into the hospital (Edmiston et al.,
2012).
Chlorhexidine gluconate (CHG) is a topical antiseptic that has been used for more
than fifty years. It is a broad spectrum antiseptic that has been found to be useful against both
gram-positive and gram-negative forming bacteria. CHG is bacteriostatic. Furthermore, it has
been found to envelope certain viruses, including HIV. CHG suppresses microbial growth for
several hours after it has been applied. There has been some concern that there could be some
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microbial resistance, however findings suggest that CHG microbial resistance is relatively low
(Edmiston et al., 2012).
Edmiston et al. (2012) speaks to patient safety being of highest importance. Therefore,
anything used on patients must have a firm safety record. CHG falls into this range. Several
studies have shown skin irritation to the patient to be rare. It has even been found safe, in lower
concentrations, in and around mucosal surfaces.
Edmiston et al. (2012) discusses seven clinical trials including 10,157 patients from 1983
to 2009. In these trials, patients bathed with CHG (4%) versus patients who bathed with a bar of
soap or performed no preoperative bathing at all. It was suggested that CHG does not
significantly reduce SSIs. However, this report revealed several issues involving flaws in the
study.
 No uniform standard of practice was set.
 No uniform duration of time was set for the patient to spend performing the pre-surgical
bath.
 No indication as to whether patients complied with the practice protocols.
 In three out of the seven studies there was no post discharge follow- up done.
 There was no documentation as to what else was being practiced after admission to the
hospital and prior to surgery.
Although the last of these studies was done in 2009, five of the seven studies were
performed prior to 1990. Therefore, advances in surgical technique, wound management, and
standardization of surgical and nursing practices since then must be taken into consideration.
CHG has been found to be an effective perioperative skin antiseptic. “In 1978, a surgical
practitioner demonstrated that application of CHG to the skin surface resulted in a greater
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microbial log reduction compared with povidone iodine” (Edmiston, et al., 2012, p. 513). It has
also been found that the effects of CHG lasted several hours after application compared with
povidone iodine.
More than twenty years ago, two separate studies determined that bathing with CHG
(4%) was more effective than that of povidone iodine or antiseptic bar soap, in reducing
staphylococcal skin colonization. It was also documented at this time that more than one
application of CHG (4%) was more effective than just a single shower. In a more recent study it
was found that a five minute a day, five day CHG (4%) bathing prior to implantation of an
artificial urinary sphincter in men, resulted in a four-fold reduction in perineal bacterial
colonization at the time of surgery versus cleansing with non-antiseptic soap and water
(Edmiston et al., 2012).
Another recent study was conducted on patients that were to have a total joint
replacement. The study took 1,464 patients and divided them into a pre-intervention group and a
post-intervention group. The pre-intervention group cleansed the night prior to surgery with a
povidone iodine solution. The post-intervention group cleansed the night prior to surgery with
CHG (2%) and upon admission to the hospital. Staff assisted the patient in cleansing the
operative site a second time. The pre-intervention SSI rate, three months post operatively was
3.19%. The post-intervention SSI rate was only 1.59%. The study gives great validity to the
importance of preadmission bathing (Edmiston et al., 2012).
In the most recent evidence based research, it is found that the benefits of pre-surgical
bathing with CHG are significant enough to warrant such practices. The importance of patient
safety in regards to avoiding SSIs is paramount. With the recent research, standardization in
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process and procedures for preoperative cleansing in elective procedures is safe and can only
improve patient outcomes.
Article Two
In the article, “Reduction of surgical site infections in low transverse cesarean section at
a university hospital”, written by Riley, Suda, Tabsh, Flood, and Pegues, (2012), cesarean
delivery rates have increased 53% from 1996 to 2007, in the United States, regardless of racial,
ethnic, geographic, maternal age, or infant gestational age strata. Not only do cesarean sections
cost more than vaginal deliveries, but medical costs are rising due to the increase in surgical site
infection (SSI) and maternal readmission. Vaginal bacteria are introduced into the uterine cavity
via the surgical incision. “The most common pathogens causing post-obstetric/gynecologic
surgery SSIs are Staphylococcus aureus (28.3%), coagulase-negative staphylococci (12.4%),
Enterococcus species (10.1%), and Escherichia coli (9.6%)” (Riley et al., 2012).
According to Riley et al., (2012) studies have been conducted that include combining
interventions to decrease the risk of post SSIs. The interventions include the use and timing of
prophylactic antibiotics, eliminating razor shaving, post-operative glycemic control, optimizing
tissue oxygen delivery, and maintaining perioperative normo-thermia. The purpose of the study,
conducted by Riley et al. (2012), was to evaluate the effectiveness of evidence-based prevention
and control strategies to reduce rates of SSI following low transverse cesarean section (LTCS).
The study took place at a 520-bed academic teaching hospital from October 2005, to
December 2008. On average, 550 LTCS were conducted annually. The study was divided into
four different time periods: baseline, outbreak period, intervention 1, and intervention 2. The
outbreak period was determined when there was a notable difference in the increase of SSI after
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LTCS (April-October 2006). A five- month period prior to the breakout period (October 2005 to
March 2006) was used as the baseline period.
During the intervention 1 period, (November 2006 to September 2007) many changes
were made. The focus was placed on changing practice and complying with CDC SSI guidelines.
The changes that were enforced were limiting surgical traffic, improving surgical hand scrub,
modifying surgical skin preparation, changing the timing of prophylactic antibiotics, revising
labor and delivery OR policies, performing SSI prevention in-services, and completing employee
competency training (Riley et al., 2012).
During the intervention 2 period, (October 2007 to December 2008), two changes to skin
preparation were implemented. Povidone-iodine was replaced with Chloroprep, a combination of
2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA). The second change was
the implementation of 2% CHG no-rinse cloths the night before the procedure. Education was
provided to patients with scheduled LTCS procedures regarding the use of 2% CHG cloths, and
not to shave at home prior to surgery. In the event of an unscheduled LTCS nurses cleansed
patients with 2% CHG cloths prior to surgery. In addition to these changes, a new hospital
facility was constructed, and the timing of prophylactic antibiotics were changed from
administering after the cord was clamped to 30 minutes prior to surgical incision.
In this study, cesarean section SSIs were classified as superficial, deep incision or organ
spaces infections (endometritis). Patients with a prior history of endometritis or endometritis
related to premature membrane rupture were excluded from the study.
Of the 1,844 LTCS procedures, 99 patients developed an SSI. This includes 44
superficial infections, 11 deep incision infections, and 44 organ spaces infections. In the baseline
period, the SSI rate was 6.27 per 100 LTCS. During the outbreak period, the SSI rate was 10.84
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per 100 LTCS. The intervention 1 period showed a 45.4% decrease in LTCS compared to the
outbreak period. The SSI rate during this period was 5.92. The intervention 2 period had an SSI
rate of 2.29 per 100 LTSC, a 61.3% decrease compared with intervention 1 period (Riley et al.,
2012).
Although there was great success in the reduction of SSIs in LTCS, there are also
numerous limitations to the study, as noted by the authors. One such limitation is the
implementation of multiple interventions at the same time. How can one determine which
intervention is successful? Alternatively, is it a combination of two or more interventions? Cost
analysis was not studied in depth. In addition, the study of prolonged labor resulting in LTCS
was not conducted. Does prolonged labor have an impact on the risk for SSI? Another limitation
is monitoring the patients to detect SSI cases. Patients were educated on the signs and symptoms
of infection and were encouraged to notify their physician if any were observed. The OBGYN
physicians were also educated to report their findings to the hospitals epidemiology department
if any potential cases were identified. Overall, the multidisciplinary approach proved effective in
the reduction of SSIs in LTCS, along with evidence based SSI prevention practices, and effective
infection prevention products (Riley et al., 2012).
Article Three
The article, “ Intraoperative Patient Skin Prep Agents is there a Difference?”, Zinn,
Jenkins, Swofford, Harrelson, and McCarter (2010), completed a comprehensive literature
review of twenty nine studies, obtained from CINAHL and PUBMED databases, that tested
several intraoperative prep agents. These included povidone iodine, chlorhexidine,
parachoroxylenol, and iodine povacylex in isopropyl alcohol, with the intent to help control SSIs
in their hospital system. Zinn, et al. (2010), were concerned that SSIs had become one of the
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most common health care associated infections, costing $845 million nationally and contributing
to 3.7 million unnecessary hospital days. The Centers for Disease Control has paid close
attention to the OR environment, including staff attire and drapes, but has lacked to provide any
recommendations to determine what surgical prep agent should be used (Zinn, et al., 2010). In
order to maintain continuity, a grid was designed and used by each group member to follow
while reviewing literature. The team also discussed the articles during biweekly meetings. The
team remarked how difficult it was to find research that reported solely on the skin preps that
their hospital was using currently. They decided to include surgical hand scrub research in the
literature review. However, they still excluded 60 articles from the 89 found because of animal
studies or the use of non-pertinent patient populations.
After the review, they concluded that there was not enough evidence to prove that
any one agent is best for all situations; since the prep agents differentiate in mechanism having
different advantages and disadvantages. When choosing a skin prep, the patients allergies and
own flora, along with the surgeons preference, and location of surgery should all be taken into
consideration. Given that many skin preps are prepared with alcohol, there is a risk for surgical
fires. These are more common with electro-surgery and laser surgery; however, providers should
be cautious. The skin prep provided should be effective against a broad spectrum of both gram
positive and gram negative microorganisms, decreasing the microorganisms count. The prep
should also be fast acting and provide continued protection against rebound and regrowth of
microorganisms.
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Article Four
The article “Decreasing Methicillin Resistant Staphylococcus Aureus Surgical Site
Infections with Chlorhexidine and Mupirocin”, Thompson and Houston, (2012), address a major
concern of healthcare organizations today: post-operative surgical site infections. A study done
by the National Health Safety network in 2007 found that 15% of these infections were caused
by methicillin-resistant staphylococcus aureus (MRSA), (Thompson & Houston, 2012). Postoperative surgical site infections make it very difficult for patients to recover from the operation
and can lead to morbidity or mortality. A surgical site infection can extend the normal recovery
time and take up to a week longer before discharge. Not only can they be detrimental to a patient,
but they also cost healthcare organizations and patients a lot of money. The Centers for Disease
Control and Prevention have estimated these infections to cost between $11,874 and $34,670 per
patient, and nationally $3.5 billion to $10 billion each year (Thompson & Houston, 2012).
Because of the problems associated with surgical site infections, there is a lot of
emphasis on trying to prevent them. Several different intra-operative and post-operative
substances have been used in the past to help reduce the risk of these infections. This study
involved the use of 2% chlorhexidine on pre-manufactured cloths to be used pre-operatively.
The Centers for Disease Control and Prevention recommend a pre-operative chlorhexidine
shower the night before surgery to help prevent surgical site infections (Thompson & Houston,
2012). This study developed a protocol to have all patients undergoing surgery in the trial to
receive 5 days of intranasal mupirocin ointment and daily bathing of 2% chlorhexidine wipes.
Over a 3 year period, 29,862 procedures were done using the developed protocol
to observe the post-operative surgical site infections that occurred. The case control facility was
well defined and included the inclusion/exclusion criteria. All adult patients having cardiac,
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orthopedic, vascular and neurological procedures were included and any craniotomy cases were
excluded (Thompson & Houston, 2012).
After the conclusion of the study, it was recommended that daily bathing with 2%
chlorhexidine pre-operatively may be beneficial to prevent MRSA related surgical site infections
(Thompson & Houston, 2012).
The non-general surgical population in the facility experienced a significant decrease in
facility acquired MRSA surgical site infections (72% decrease during 2006-2008) with the
addition of prophylactic 5-day course of intranasal mupiricin and daily cleansing with 2% nonrinse chlorhexidine cloths.
Analysis of Evidence
The overall evidence provided by the first article is strong in supporting the use of CHG.
The evidence also supported that not any one method alone was sufficient. The standardization
of application time as well as education and patient compliance is also of great significance. The
authors did identify some weaknesses within the included studies. One study listed several
problematic issues such as study design, implementation, and analysis. Another weakness noted
during the review of the article is due to the length of the literature review containing several
studies. The authors were forced to eliminate a large portion of pertinent information to fit the
article in the printed journal.
The statistical data provided in the second article showed there was a great improvement
in the decrease of SSIs by 63.5% over the 39 month period. The negative aspects of the study
included the fact that the researchers changed several policies over the course of the study.
These changes were not adequately described to the reader. Due to the numerous changes, how
can the researchers determine what changes provided the positive evidence? The authors stated
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the change of skin prep to CHG was the last change implemented because they had not seen the
results they wanted from previous changes. This fact indicates there is strong evidence that
Chlorhexidine does reduce SSIs. The researchers also agreed it was difficult to monitor patients
for SSI after discharge.
The third article provides easy to read information and charts that compare several skin
prep agents obtained from 29 articles. The authors state each team member followed a guideline
while collecting information from articles and committed to biweekly meetings to discuss the
findings of the literature review. Unfortunately, the authors stated they did not find enough
evidence to conclude an argument that one skin prep agent is the best in all situations. The
article lacked statistical data to support the research and included several unanswered questions.
The article also had variations in its study design on how and where the skin prep was applied.
The fourth article provides strong evidence that the use of CHG as a general surgery skin
preparation decreased MRSA SSIs by 72%. The study included 29,000 patients over a three year
period. The study design was well controlled providing good definitions of inclusion and
exclusion criteria. Interventions were well documented. Two weaknesses were noted during the
review. It was difficult to evaluate compliance, and since researchers implemented two
interventions simultaneously it is difficult to determine which treatment was most effective.
Review of Practice
As nurses, we always want what is best for our patients. In the studies of chlorhexidine use,
there is a lot of evidence to show that it is effective at decreasing surgical site infections. There
are institutions such as the Institute for Hospital Improvement (IHI) that are encouraging the use
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for chlorhexidine pre-operative showers and a chlorhexidine-alcohol for total joint surgeries.
Chlorhexidine is also being used for central line placement and is impregnated in some of the
dressings used.
Recommendations
After evaluating the evidence, the use of chlorhexidine for pre-operative and intraoperative asepsis is recommended. It is already being used by most healthcare organizations and
with success. According to the studies reviewed, the use of chlorhexidine could save healthcare
organizations thousands of dollars and billions of dollars nationally. Fewer post- operative
infections will also lead to higher patient satisfaction and a better experience in the hospital.
Conclusion
The literature this group reviewed provided an exemplary amount of research regarding
CHG use in the attempt to prevent surgical site infections. There is sufficient evidence that
suggests CHG is not only an effective pre-operative antiseptic but is safe as well. In the
literature, it is also found that CHG is superior to the use of povidone iodine for prevention of
SSIs. Use of CHG improves patient outcomes and saves the United States millions of health care
dollars annually.
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References
Edminster, C.E. Jr, Okoli, O., Graham, M.B., Sinski, S., & Seabrook, G.(2010). Evidence for
using chlorhexidine gluconate preoperative cleansing to reduce risk of surgical site
infection. Association of Perioperative Registered Nurses Journal, 92(5), 509-518.
Riley, M., Suda, D., Tabsh, K., Flood, A., & Pegues, D. (2011). Reduction of surgical site
infections in low transverse cesarean section at a university hospital. American Journal of
Infection Control, doi:10.1016/j.ajic.2011.12.011
Thompson, P., Houston, S. (2012). Decreasing methicillin-resistant staphylococcus aureus
surgical site infections with chlorhexidine and mupirocin. American journal of infection
control, 9(3).
Zinn, J., Jenkins, J., Swofford, V., Harrelson, B., & McCarter, S. (2010). Intraoperative patient
skin prep agents: Is there a difference? Association of Perioperative Registered Nurses
Journal, 92(6), 662-671. doi:10.1016/j.aorn.2010.07.016