Cost-effectiveness analysis of the use of chlorhexidine detergent in preoperative whole-body disinfection in wound infection prophylaxis.

A total of 3482 general surgical patients entered a trial in which they had a chlorhexidine or placebo detergent shower three times before elective clean wound or potentially contaminated surgery. Patients who showered with a chlorhexidine detergent (N = 1744) had a significant reduction in skin flora compared with those who showered with a placebo detergent (N = 1738). The majority of wound infections occurred outside hospital (312 outpatient infections vs. 201 inpatient infections). Wound infection rates were similar in the chlorhexidine and placebo groups (5.79% vs. 5.75% for inpatient infections and 8.54% vs. 9.38% for outpatient infections). The average hospital cost of both non-infected and infected patients was higher in the chlorhexidine group. The average cost of a non-infected chlorhexidine patient was 847.95 pounds as opposed to 804.60 pounds for a non-infected placebo patient, whilst the average cost of an infected patient was 1459.70 pounds (chlorhexidine) and 1414.22 pounds (placebo). A cross-match comparison of patients undergoing vascular surgery revealed no statistical significance in the difference between the two experimental groups. Patients were matched for age, sex, type of operation and surgeon. We conclude that preoperative whole-body disinfection with a chlorhexidine detergent is not a cost-effective treatment for reducing wound infection.     

A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates

The effect of preoperative whole-body washing with chlorhexidine detergent on the incidence of postoperative wound infection was assessed in a placebo-controlled trial of 1989 patients. Patients bathed or showered with chlorhexidine, placebo, or conventional bar soap, on two occasions in the 24 h before operation. The overall infection rate for patients treated with chlorhexidine was 9%, against 12.8% in the bar soap and 11.7% in the placebo groups; in the 'clean' surgery group infections were 7.2% against 10.2% and 10%, respectively. The Staphylococcus aureus infection rate in the 'clean' group was 3% for chlorhexidine against 6% for bar soap.     

A comparison of the use of povidone-iodine and chlorhexidine in the prophylaxis of postoperative wound infection

Povidone-iodine and chlorhexidine surgical scrub and skin preparation solutions were assessed by comparing postoperative wound infection rates in a prospective, randomized study of 866 patients.The frequency of wound infection overall, as agreed by two observers, was 14·8 per cent in the povidone-iodine group and 9·7 per cent in the chlorhexidine group (P = 0·03) at the time of patients' discharge from hospital. The difference between the compounds was not significant at a ‘standard’ observation period of three to four days after operation. There were significantly fewer infections with chlorhexidine than with povidone-iodine in operations on the biliary tract and in ‘clean’ non-abdominal operations, but there were more infections (not significantly so) with chlorhexidine than with povidoneiodine in large bowel surgery, other laparotomies and in operations on hernia, genitalia and varicose veins. The differences in bacterial isolates from wounds tended to follow the above patterns.We conclude that, on the evidence of this study, there is no overwhelming case for using one compound rather than the other as an all-purpose preparation and scrub.     

Source and route of methicillin-resistant Staphylococcus epidermidis transmitted to the surgical wound during cardio-thoracic surgery. Possibility of preventing wound contamination by use of special scrub suits

The objective of this study was to trace the source and route of transmission of methicillin-resistant Staphylococcus epidermidis (MRSE) in the surgical wound during cardio-thoracic surgery, and to investigate the possibility of reducing wound contamination by wearing special scrub suits. In total 65 elective operations for coronary artery bypass grafting (CABG) with or without concomitant valve replacement were investigated. All staff present in the operating room wore conventional scrub suits during 33 operations and special scrub suits during 32 operations. Samples were taken from the hands of the scrubbed team after surgical scrub but before putting on sterile gowns and gloves, and from patients' skin (incisional area of sternum and vein harvesting area of legs) after preoperative skin preparation with chlorhexidine gluconate. Air samples were taken during operations. Samples were also taken from the wound just before closure. Total counts of bacteria on sternal skin and from the wound (cfu/cm2) were calculated as well as total counts of bacteria in the air (cfu/m3). Strains of MRSE recovered from the different sampling sites were compared by pulsed field gel electrophoresis (PFGE). It was found that wearing special scrub suits did not reduce the number of air-samples where MRSE was found compared with conventional scrub suits. The risk factor most strongly associated with MRSE in the wound at the end of the operation was preoperative carriage of MRSE on sternal skin; RR 2.42 [95% CI 1.43-4.10], P= 0.021. By use of PFGE, it was possible to identify the probable source for four MRSE isolates recovered from the wound. In three cases the source was the patients own skin. Finding MRSE in air-samples, or on the hands of the scrubbed team, were not risk factors for the recovery of MRSE in the wound at the end of operation. In conclusion, with a total bacterial air count around 20 cfu/m3 and a low proportion of MRSE, the reduction of total air counts by use of tightly woven special scrub suits did not reduce air counts of MRSE or wound contamination with MRSE. The patients' sternal skin was the main source for wound contamination with MRSE Copyright 2001 The Hospital Infection Society.     

术前皮肤准备对预防手术部位感染的作用探讨

目的探讨手术部位皮肤准备方式及时间,预防手术部位感染。方法术前使用2％葡萄糖氯己定或抗菌皂液沐浴或擦拭清洁手术部位;当手术野毛发较粗长、确需去除时,在术前即刻用不损伤皮肤的电动发剪剪毛。结果使用有消毒性能的清洁剂彻底清除手术切口部位和周围皮肤的污染和手术前即刻去除手术部位毛发,达到卫生部《外科手术部位感染预防和控制技术指南（试行）》要求。结论彻底清洁手术部位皮肤和术前即刻去毛,能有效减少局部皮肤表面的细菌数量,降低术后切口感染率。     

The effect of whole body disinfection on intraoperative wound contamination.

As part of a large whole body disinfection (WBD) trial two small sub-groups of patients who showered preoperatively with either a 4% chlorhexidine (CHX: N = 29) or placebo (N =27) detergent were studied to assess intraoperative wound contamination. The groups were well matched for age, sex and length of surgery. A membrane filter contact technique was used for bacterial recovery from the wounds after the initial skin incision and before wound closure. The membrane filters were incubated aerobically on blood agar plates with a CHX neutralizer for 48 h at 37 degrees C and colonies were counted. The results show a significant difference, between the bacterial counts at the start and end of surgery in the CHX and placebo groups. There was no difference in bacterial counts at the start of surgery between the CHX and placebo groups. There was a significant difference in the bacterial counts at the end of surgery between the CHX and placebo groups. These results indicate that preoperative WBD with CHX reduces intraoperative wound contamination but the effect of this on postoperative wound sepsis rates awaits the results of a large WBD trial.     

Routes and sources of Staphylococcus aureus transmitted to the surgical wound during cardiothoracic surgery: possibility of preventing wound contamination by use of special scrub suits.

OBJECTIVES: To trace the routes of transmission and sources of Staphylococcus aureus found in the surgical wound during cardiothoracic surgery and to investigate the possibility of reducing wound contamination, with regard to total counts of bacteria and S. aureus, by wearing special scrub suits. METHODS: A total of 65 elective operations for coronary artery bypass graft with or without concomitant valve replacement were investigated. All staff present in the operating room wore conventional scrub suits during 33 operations and special scrub suits during 32 operations. Bacteriological samples were taken from the hands of the scrubbed team after surgical scrub but before putting on sterile gowns and gloves and from the patients' skin (incisional area of sternum and vein harvesting area of legs) after preoperative skin preparation with chlorhexidine gluconate. Air samples were taken during operations. Bacteriological samples also were taken from the subcutaneous walls of the surgical wound just before closing the wound. Total counts of bacteria on sternal skin and wound walls (colony-forming units [CFUs]/cm2) were calculated, as well as total counts of bacteria in the air (CFUs/m3). Strains of S. aureus recovered from the different sampling sites were compared by pulsed-field gel electrophoresis (PFGE). RESULTS: Special scrub suits significantly reduced total counts of bacteria in air compared to conventional scrub suits (P=.002). The number of air samples in which S. aureus was found was significantly reduced by special scrub suits compared with conventional scrub suits (P=.016; relative risk, 4.4; 95% confidence interval [CI95], 1.3-14.91). By use of PFGE, it was possible to identify two cases of possible airborne transmission of S. aureus when wearing conventional scrub suits, whereas no case was found when wearing special scrub suits. When exposed to airborne S. aureus, the concomitant sternal carriage of S. aureus was a risk factor for having S. aureus in the wound. CONCLUSIONS: Use of tightly woven special scrub suits reduces the dispersal of total counts of bacteria and of S. aureus from staff in the operating room, thus possibly reducing the risk of airborne contamination of surgical wounds. The importance of careful preoperative disinfection of the patient's skin should be stressed.     

An in-use evaluation of an alcohol-based pre-surgical hand disinfectant.

OBJECTIVE: To determine whether alcohol hand disinfection is an effective alternative to traditional agents for the pre-surgical scrub. DESIGN: A prospective clinical trial of a 70% isopropanol pre-surgical hand disinfectant. SETTING: The operating room suites at two hospital sites in British Columbia. METHODS: Cases were selected to evaluate both short and longer procedures. The hand disinfectant was compared to agents in current use as surgical scrubs (4% chlorhexidine and 7.5% povidone-iodine). Surgical technique and glove use were not modified. Pre- and postoperative fingertip impression and "glove-juice" cultures were used to determine microbial burden, and hands were evaluated for skin integrity. RESULTS: There was no statistical difference between the microbial hand counts following use of the alcohol-based product or the current agents, for cases less than 2 hours' duration. Comparison of longer surgical cases revealed significantly better pre- and postoperative culture results with the alcohol hand rinse, but analysis of matched pairs showed no significant difference in microbial counts. The alcohol hand rinse was equivalent to the operative scrub in terms of skin integrity and user acceptability. CONCLUSION: An alcohol hand rinse was equivalently effective in reducing microbial hand counts as the traditional pre-surgical scrub, both immediately after hand disinfection and at the end of the surgical procedure.     

Rationalizing whole body disinfection

As part of the preparation for a large prospective trial investigating the effect of preoperative whole body disinfection on the postoperative wound infection rate, this preliminary volunteer study was carried out to establish (a) the optimum number of preoperative washes required to achieve a maximum level of skin disinfection and (b) if showering or bathing is a more efficient method of skin disinfection. Ten healthy volunteers were recruited. The results show a significant decrease (p less than 0.005) in the skin flora after the first and second showers (a decrease of 93.55% and 77.49% respectively), but no further significant fall with subsequent showers. There was a significant fall (p less than 0.005) in skin flora after a single bath (a decrease of 70.98%) with subsequent baths producing no further significant reduction in skin flora. From these results it is recommended that three preoperative showers with 4% chlorhexidine detergent be used as an optimum preoperative whole body disinfection regimen. Three showers ensures against less thorough washing by the patients compared to the healthy volunteers in the study and fits easily into a preoperative regimen.     

不同换药方式对甲周感染伤口换药效果的观察

目的 探索护理甲周感染伤口痛苦小、且愈合快的换药方法.方法 将患者分为两组:擦洗组:2007年5月-2008年9月30例伤口采用传统擦洗法;浸泡冲洗组:2008年10月-2010年5月30例伤口采用0.5％聚维酮碘浸泡+生理盐水冲洗法;观察两组病例伤口愈合时间,患者对疼痛的反应及晕厥发生率.结果 浸泡冲洗组无一例患者发生晕厥,换药时疼痛分值(4.90±2.64)分,明显低于擦洗组的(8.97±0.10)分;伤口愈合时间(13.10±5.59)d,明显快于擦洗组的(19.00±3.32)d,差异有统计学意义(P＜0.05).结论 应用0.5％聚维酮碘浸泡+生理盐水冲洗换药方法,可有效减轻患者疼痛,加速伤口愈合.     

Proteeae groin skin carriage among nursing home residents--resistance to antiseptics

Proteeae carriage was evaluated in groin skin carriers following vigorous antiseptic application. Three Proteus mirabilis carriers were treated with 60% isopropyl alcohol or 4% chlorhexidine, observed to prevent skin contact, and then recultured; at four and eight hours P mirabilis numbers remained undiminished. Ten Proteeae carriers received a series of nine body baths with soap, chlorhexidine, and 0.75% povidone-iodine plus three cefazolin injections over 16 to 34 days; cumulative treatments failed to clear seven carriers. Within three months, all were again carriers. Proteeae carriers also had affinity for groin carriage of various aerobic gram-negative bacilli (AGNB) including cefazolin-resistant strains. In seven subjects, more than one AGNB species were recovered shortly after applying an antiseptic. Proteeae groin skin carriage appears to reflect a major change in the nature of resident bacteria on intact groin skin.     

A randomized,prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector

The microbial contamination rate of luers of central venous catheters (CVCs) with either PosiFlow needleless connectors or standard caps attached was investigated. The efficacy of 70% (v/v) isopropyl alcohol, 0.5% (w/v) chlorhexidine in gluconate 70% (v/v) isopropyl alcohol and 10% (w/v) aqueous povidone-iodine to disinfect the intravenous connections was also assessed. Seventy-seven patients undergoing cardiac surgery who required a CVC as part of their clinical management were randomly allocated either needleless connectors or standard caps. Patients were also designated to receive chlorhexidine/alcohol, isopropyl alcohol or povidone-iodine for pre-CVC insertion skin preparation and disinfection of the connections. After 72 h in situ the microbial contamination rate of 580 luers, 306 with standard caps and 274 with needleless connectors attached, was determined. The microbial contamination rate of the external compression seals of 274 needleless connectors was also assessed to compare the efficacy of the three disinfectants. The internal surfaces of 55 out of 306 (18%) luers with standard caps were contaminated with micro-organisms, whilst only 18 out of 274 (6.6%) luers with needleless connectors were contaminated (P<0.0001). Of those needleless connectors disinfected with isopropyl alcohol, 69.2% were externally contaminated with micro-organisms compared with 30.8% disinfected with chlorhexidine/alcohol (P<0.0001) and 41.6% with povidone-iodine (P<0.0001). These results suggest that the use of needleless connectors may reduce the microbial contamination rate of CVC luers compared with the standard cap. Furthermore, disinfection of needleless connectors with either chlorhexidine/alcohol or povidone-iodine significantly reduced external microbial contamination. Both these strategies may reduce the risk of catheter-related infections acquired via the intraluminal route.     

Effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing.

The effectiveness of various hand washing and disinfection methods in removing transient skin bacteria was studied in hospital after dry or moist contamination of the hands when nursing burn patients. The results were compared with those of laboratory tests with volunteers. A fairly good correlation of the bacterial reductions existed between hospital and laboratory tests. All other methods removed Staph. aureus from the hands more effectively than liquid soap. Gram-negative bacilli were more easily removed than staphylococci, even with soap wash alone. In hospital, none of the washing and disinfection methods always removed all patient-borne bacteria from the hands. After dry or moist contamination and subsequent washing with soap only, colonies of Staph. aureus were often detected in finger-print samples. Staphylococci were more often completely removed by a 4% chlorhexidine detergent scrub and alcoholic solutions (either with or without previous soap wash) than by liquid soap, hexachlorophene or iodophor preparations. Gram-negative bacilli were more easily removed by all the washing and disinfection methods. After moist contamination, Gram-negative bacilli were more often completely removed from the hands by ethanol than by other treatments. The results of the present study emphasize the importance of always using gloves when nursing a profuse spreader of bacteria or one who must be protected from infection.     

不同外科手消毒方法对手部皮肤影响的研究

目的比较3种常用外科手消毒方法对手部皮肤的影响。方法选择含乙醇无水洗手液揉搓、碘伏海绵擦手和碘伏刷手等3种外科手消毒方法,比较其即刻消毒效果和对手部皮肤的影响。结果3种外科手消毒方法都有良好的即刻消毒效果,含乙醇无水洗手液揉搓方法较碘伏消毒方法对皮肤损伤小。结论在外科手消毒时建议使用无水洗手液揉搓消毒的方法。     

Effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing

The effectiveness of various hand washing and disinfection methods in removing transient skin bacteria was studied in hospital after dry or moist contamination of the hands when nursing burn patients. The results were compared with those of laboratory tests with volunteers. A fairly good correlation of the bacterial reductions existed between hospital and laboratory tests. All other methods removed Staph. aureus from the hands more effectively than liquid soap. Gram-negative bacilli were more easily removed than staphylococci, even with soap wash alone. In hospital, none of the washing and disinfection methods always removed all patient-borne bacteria from the hands. After dry or moist contamination and subsequent washing with soap only, colonies of Staph. aureus were often detected in finger-print samples. Staphylococci were more often completely removed by a 4% chlorhexidine detergent scrub and alcoholic solutions (either with or without previous soap wash) than by liquid soap, hexachlorophene or iodophor preparations. Gram-negative bacilli were more easily removed by all the washing and disinfection methods. After moist contamination, Gram-negative bacilli were more often completely removed from the hands by ethanol than by other treatments. The results of the present study emphasize the importance of always using gloves when nursing a profuse spreader of bacteria or one who must be protected from infection.     

Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers.

OBJECTIVE: To evaluate the efficacy of a standardized regimen for decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers and to identify factors influencing decolonization treatment failure. DESIGN: Prospective cohort study from January 2002 to April 2007, with a mean follow-up period of 36 months. SETTING: University hospital with 750 beds and 27,000 admissions/year. PATIENTS: Of 94 consecutive hospitalized patients with MRSA colonization or infection, 32 were excluded because of spontaneous loss of MRSA, contraindications, death, or refusal to participate. In 62 patients, decolonization treatment was completed. At least 6 body sites were screened for MRSA (including by use of rectal swabs) before the start of treatment. INTERVENTIONS: Standardized decolonization treatment consisted of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days. Intestinal and urinary-tract colonization were treated with oral vancomycin and cotrimoxazole, respectively. Vaginal colonization was treated with povidone-iodine or, alternatively, with chlorhexidine ovula or octenidine solution. Other antibiotics were added to the regimen if treatment failed. Successful decolonization was considered to have been achieved if results were negative for 3 consecutive sets of cultures of more than 6 screening sites. RESULTS: The mean age (+/- standard deviation [SD]) age of the 62 patients was 66.2 +/- 19 years. The most frequent locations of MRSA colonization were the nose (42 patients [68%]), the throat (33 [53%]), perianal area (33 [53%]), rectum (36 [58%]), and inguinal area (30 [49%]). Decolonization was completed in 87% of patients after a mean (+/-SD) of 2.1 +/- 1.8 decolonization cycles (range, 1-10 cycles). Sixty-five percent of patients ultimately required peroral antibiotic treatment (vancomycin, 52%; cotrimoxazole, 27%; rifampin and fusidic acid, 18%). Decolonization was successful in 54 (87%) of the patients in the intent-to-treat analysis and in 51 (98%) of 52 patients in the on-treatment analysis. CONCLUSION: This standardized regimen for MRSA decolonization was highly effective in patients who completed the full decolonization treatment course.     

Shedding of bacteria and skin squames after handwashing.

Particles released into the air by wringing the hands together were collected in a slit sampler before and after washing with bar soap, with three surgical scrubs, and after rubbing them with a spirit-based lotion. The particles were identified, their number estimated, those that bore bacteria counted, and the bacteria themselves classified. It was found that there was a significant increase, averaging 17-fold, in the number of particles carrying viable bacteria released after washing with soap. The increase in bacterial dissemination was suppressed if a surgical scrub was used in place of soap, or when the lotion was used without washing. The number of skin squames released increased by 18-fold or more after washing with soap or a surgical scrub, but not after using the lotion. This suggests that a surgical scrub should be used more widely in clinical practice, and that a spirit-based hand lotion might with advantage become a partial substitute for handwashing, particularly in areas where handwashing is frequent and iatrogenic coagulase-negative staphylococcal infection common.     

The relative importance of routes and sources of wound contamination during general surgery. I. Non-airborne.

A study was undertaken to determine the relative importance of some sources, routes of transmission, and measures to prevent bacteria entering the wound during biliary tract surgery. When bacteria were growing in the bile they accounted for the majority (greater than 99%) of the bacteria found in the wound. However, when the bile was sterile the skin bacteria at the incision site were found to make a substantial contribution to the wound flora. The difference in the total wound contamination between a patient who had practically no skin bacteria and one who had an average amount was in the region of 17-fold. No transfer of skin bacteria from the surgical team through perforated gloves or by direct contact from the surface of operating gowns was demonstrated. Ten of the patients studied had septic wounds. Five of these were infected by bacteria from the bile.     

A randomized, controlled trial of tea tree topical preparations versus a standard topical regimen for the clearance of MRSA colonization

Two topical MRSA eradication regimes were compared in hospital patients: a standard treatment included mupirocin 2% nasal ointment, chlorhexidine gluconate 4% soap, silver sulfadiazine 1% cream versus a tea tree oil regimen, which included tea tree 10% cream, tea tree 5% body wash, both given for five days. One hundred and fourteen patients received standard treatment and 56 (49%) were cleared of MRSA carriage. One hundred and ten received tea tree oil regimen and 46 (41%) were cleared. There was no significant difference between treatment regimens (Fisher's exact test; P = 0.0286). Mupirocin was significantly more effective at clearing nasal carriage (78%) than tea tree cream (47%; P = 0.0001) but tea tree treatment was more effective than chlorhexidine or silver sulfadiazine at clearing superficial skin sites and skin lesions. The tea tree preparations were effective, safe and well tolerated and could be considered in regimens for eradication of MRSA carriage.     

75％酒精与0．5％碘伏用于鼻内窥镜手术后感染状态的研究

目的探讨75％酒精及0．5％碘伏用于鼻窦内窥镜手术面部皮肤消毒效果及对鼻腔术后感染的影响。方法将1850例经鼻内窥镜下行鼻窦手术患者,采用随机分为75％酒精消毒为实验组（A）和0．5％碘伏消毒对照组（B）,每组各925例,观察两组皮肤存茵、术后鼻腔感染情况。结果两种消毒方法皮肤除茵率A组高于B组,差异有统计学意义;发生手术部位感染A组为1例,B组为3例,均为轻度感染,经消炎换药后均痊愈出院。结论两种消毒液均安全可靠．75％酒精可用于鼻内镜鼻窦手术面部皮肤消毒,替代传统的碘伏消毒方法。