Presented by:
Cindy Magirl
Eric Nelson
Tennille Sassano
Jennifer Vicarie
What does the literature say about the use of
Chlorhexidine in the prevention of surgical site
infections (SSI’s)?
• It is estimated that between 750,000 and 1 million
SSIs occur in the United States each year (Edmiston et
al., 2010).
• SSIs remains a substantial cause of post-operative
morbidity and increased health care costs (Riley et al.,
2012).
• SSIs result in 3.7 million additional hospital days and
$845 million spent nationally. (Zinn et al., 2010)
The aim is to
evaluate the
effectiveness of
evidence-based
prevention and
control strategies
to reduce rates
of SSIs.
Patient (intrinsic)
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Procedural (extrinsic)
Age
Diabetes (metabolic disease)
Perioperative hyperglycemia
Tobacco use
Concurrent infection (distant)
Obesity
Malnutrition
Immunocompromise
Low preoperative serum albumin level
Corticosteroid use
Prolonged hospitalization before
surgery
• Prior radiation to surgical field tissue
• Staphylococcus aureus colonization
• Lack of preoperative shower
• Site shaving the night before
surgery
• Extended operative time
• Flawed skin antisepsis
• Flawed surgical prophylaxis
• Effects of the OR environment (eg,
hypothermia)
• Break in aseptic technique
• Hypothermia or hypoxia
• Perioperative blood transfusion
• Surgical technique
• Hemostasis
• Tissue trauma
Edmiston et al., 2010
• 1978 – study showed that application of CHG to the
skin surface resulted in a greater microbial log
reduction and it persisted several hours after
application compared with povidone iodine
• 1988 – documentation shows that repeat application
of CHG 4% was superior to a single shower in
reducing staphylococcal skin contamination
Edmiston et al., 2010
PRE-INTERVENTION
GROUP
• 727 patients
• Self bathing of povidone
iodine night prior to
surgery
• After 3 months, 3.19%
infection rate
POST-INTERVENTION
GROUP
• 737 patients
• Self bathing of CHG 2%
impregnated polyester
cloths night prior to
surgery and staff
assisted bath on
admission to hospital
• After 3 months, 1.59%
infection rate
Edmiston et al., 2010
Overall the evidence is strong in supporting the use of CHG. In
the journal article, the authors identify some weakness within the
studies they included. For example, in one of the studies the
author lists several problematic issues involving study design,
implementation, and analysis. Another weakness of this literature
review is several studies were included and because of this, there
was a lot of pertinent information left out in order to summarize
the amount of information.
• Observational study conducted to determine LTCS SSI rates and
impact of infection control interventions from Oct. 2005-Dec.
2008
• Included use of 2% Chlorhexidine gluconate (CHG) for surgical
skin prep and no rinse CHG cloths
• Four study periods
Riley et. al, 2012
Baseline Period
(October, 2005 - March, 2006)
SSI rate retrospective identification for comparison
Riley et al., 2012
Outbreak Period
(April, 2006 – October, 2006)
• Obstetrics and gynecology (OBGYN) clinicians noticed an increase in
post-LTCS patients returning with SSI in 2006
• Focused on identifying critical control points and analyzing hazards by
directly observing LTCS procedures
• Labor and delivery (L&D) operating room (OR) walks
• Self administered employee survey
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Limited personnel traffic during surgery
Improved surgical hand scrub
Modified surgical skin preparation
Changed the timing of antimicrobial prophylaxis
Revised L&D OR policies
Performed SSI prevention in-services
Completed employee competency training
Intervention One Period
(November, 2006 – September, 2007)
• Focused on changing practice and fully implementing all
recommendations from outbreak period
• Fully implemented recommendations based on the CDC’s SSI
prevention guidelines
Intervention Two Period
(October, 2007 - December, 2008)
• Chloroprep, a combination of 2% CHG and 70% isopropyl
alcohol (IPA) replaced povidone-iodine for surgical skin prep
• Implementation of preoperative CHG skin cleansing program
• Scheduled – patient performed night before surgery
• Unscheduled – nurse performed as part of pre-surgery prep
• Moved into new hospital building
• Changed administration time of antibiotic
• Nurses in OBGYN clinics educated patients about SSI
prevention
Evidence in itself was strong based on the reduction of
SSIs during the study. However, there were also several
limitations to the study:
• Implementation of multiple interventions at the same
time. Which intervention was successful?
• Cost analysis was not studied in depth.
• Although patients were instructed to contact their
physician for signs and symptoms of infection, no
official follow-up was coordinated.
• The authors conducted an article review to evaluate if there is a
superior intra-operative prep available for open abdominal
and general surgery procedures.
• The authors concluded that there is no one prep that is superior
in all situations.
Zinn et al., 2010
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Povidone-iodine
Advantages
Excellent gram-positive
activity
Good gram-negative
activity
Broad spectrum
Moderate rapidly of action
Long established as an
effective agent
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Chlorhexidine
Advantages
Excellent gram-positive
activity
Good gram-negative activity
Broad spectrum
Moderate rapidly of action
Excellent persistent and
residual activity
Zinn et al., 2010
Povidone- iodine
Disadvantages
• Minimal persistence and
residual activity
• Decreased effectiveness in
the presence of blood and
organic material
• Lack of recent empirical
evidence
Chlorhexidine
Disadvantages
• Contraindicated for use on
eyes, ears, brain and spinal
tissue, genitalia, mucus
membranes
• Inactivity in the presence of
saline solution
• Drying effect on the skin
Zinn et al., 2010
• Only 29 studies were involved in this literature review
• Each prep agent has specific advantages and
disadvantages.
• The study reviewed several prep agents because of the
considerations for patient allergies, natural flora, surgical
site, and surgeon preference.
• The study did not include any research of ChloraPrep
• The researchers stated that they did not find adequate
information to prove one prep agent used exclusively.
• The article was easy to read however lacked specific
information or statistical evidence; leaving a lot of
unanswered questions.
• This was a case controlled study of 29,862 patients over a 3
year period
• Only orthopedic, cardiac, neurological, and vascular cases were
in the study
Thompson & Houston, 2012
• To determine if a regimen of 2% chlorhexidine for 5 days preop along with intra-nasal mupiricin decreases MRSA surgical
site infections
Thompson & Houston, 2012
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Cardiac 92% decrease
Orthopedic 43% decrease
Neurology 100% decrease
Vascular 52% decrease
• Total MRSA SSI reductions from 2006-2008
Thompson & Houston, 2012
• Pre-operative bathing with 2% chlorhexidine and use of
mupiricin ointment may be beneficial in reducing MRSA SSI’s
• We currently use a variety of products
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ChloraPrep w/ tint
4% chlorhexidine solution
ChloraPrep SEPP
2% chlorhexidine cloths
• Use of chlorhexidine intra-op skin prep when not
contraindicated
• Appropriate education to patients and staff about use and
application
• Pre-operative chlorhexidine bathing
• Ongoing follow up on post operative infection rate
• 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
• CMPA Good Practices Guide. 2012. [Surgical Preparation].
Retrieved from http://www.cmpa-acpm.ca
• Mayo Healthcare Pty. Ltd. n.d. Interventional Hygiene. Retrieved
from
http://www.mayohealthcare.com.au/products/Resp_intvH
ygiene_skinPrep.htm