Evidence base of pre-op skin preparation

admin · May 2, 2005

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The latest Journal of Bone and Joint Surgery has two papers on pre-operative skin preparation for foot and ankle surgery. Good to see such mundane and taken for granted topics getting attention:

Efficacy of Surgical Preparation Solutions in Foot and Ankle Surgery
Roger V. Ostrander, Michael J. Botte and Michael E. Brage

Background:
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Previous studies have demonstrated higher infection rates following orthopaedic procedures on the foot and ankle as compared with procedures involving other areas of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to evaluate the efficacy of three different surgical skin-preparation solutions in eliminating potential bacterial pathogens from the foot.
Methods: A prospective study was undertaken to evaluate 125 consecutive patients undergoing surgery of the foot and ankle. Each lower extremity was prepared with one of three randomly selected solutions: DuraPrep (0.7% iodine and 74% isopropyl alcohol), Techni-Care (3.0% chloroxylenol), or ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). After preparation, quantitative culture specimens were obtained from three locations: the hallux nailfold (the hallux site), the web spaces between the second and third and between the fourth and fifth digits (the toe site), and the anterior part of the tibia (the control site).
Results: In the Techni-Care group, bacteria grew on culture of specimens obtained from 95% of the hallux sites, 98% of the toe sites, and 35% of the control sites. In the DuraPrep group, bacteria grew on culture of specimens obtained from 65% of the hallux sites, 45% of the toe sites, and 23% of the control sites. In the ChloraPrep group, bacteria grew on culture of specimens from 30% of the hallux sites, 23% of the toe sites, and 10% of the control sites. ChloraPrep was the most effective agent for eliminating bacteria from the halluces and the toes (p < 0.0001).
Conclusions: The use of effective preoperative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in foot and ankle surgery. Of the three solutions tested in the present study, the combination of chlorhexidine and alcohol (ChloraPrep) was most effective for eliminating bacteria from the forefoot prior to surgery.
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Preoperative Skin Preparation of the Foot and Ankle: Bristles and Alcohol Are Better
David J. Keblish, David Zurakowski, Michael G. Wilson, and Christopher P. Chiodo

Background:
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The most efficient way to prepare the skin for foot and ankle surgery is unknown. In recent studies, >70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidone-iodine were positive. The goal of the current study was to determine the effect of isopropyl alcohol on the eradication of bacteria from the nails and skin of the normal foot and ankle. In addition, the effect of using a bristled brush rather than sponges to scrub the foot was investigated.
Methods: Four skin-preparation techniques were studied in two sets of twenty-five volunteers. In phase I of the study, the right foot and ankle of each member of the first set of volunteers was prepared with method 1, which consisted of a two-stage povidone-iodine scrub and paint with use of soft sponges. The left foot and ankle was prepared with method 2, which consisted of method 1 as well as an additional prewash with 70% isopropyl alcohol. In phase II, the right foot and ankle of each member of the second set of volunteers was prepared with method 3, which consisted of a povidone-iodine scrub and paint with use of a bristled brush to scrub the foot. The left side was prepared with method 4, which consisted of an alcohol scrub and paint with use of a bristled brush to scrub the foot. At the end of the preparation process, specimens for aerobic bacterial cultures were obtained from the hallucal nail fold, interdigital web spaces, and anterior aspect of the ankle. Cultures were interpreted as positive or negative, and the results were also assessed quantitatively.
Results: The rates of positive cultures of the nail-fold specimens were 76% and 80% after methods 1 and 2 (soft sponges) and 76% and 12% after methods 3 and 4 (bristled brush). The reduction in the percentage of positive cultures with method 4 was highly significant (p < 0.001). Cultures of the specimens from the web spaces showed a significant difference in the rates of positive results between methods 1 and 2 (36% and 8%, p < 0.05) but no significant difference between methods 3 and 4 (12% and 0%, p = 0.25). The rates of positive cultures of specimens from the anterior aspect of the ankle were consistently low (4% for all methods). Quantitative analysis of positive cultures demonstrated significant reductions (p < 0.01) in heavy growth when bristled brushes had been used, both with povidone-iodine and isopropyl alcohol.
Conclusions: The use of isopropyl alcohol and the use of a bristled brush both have beneficial effects on the skin-preparation process before foot and ankle surgery. In the current investigation, the most effective technique was the use of isopropyl alcohol in conjunction with scrubbing with a bristled brush. Merely washing the foot with alcohol-soaked sponges provided limited benefit to the web spaces only.
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NewsBot · Aug 12, 2009

Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load.
de Bengoa Vallejo RB, Losa Iglesias ME, Cervera LA, Fernández Bpharm DS, Prieto JP.
J Am Acad Dermatol. 2009 Aug 6

BACKGROUND: Orthopedic surgical procedures involving the foot and ankle are associated with high rates of infection. The optimal method of preparing the skin and nails for foot and ankle surgery remains unknown.

OBJECTIVE: This study was conducted to compare the efficacy of 4 different methods of skin and nail preparation of the foot using various antiseptic solutions.

METHODS: In this prospective, randomized study, 4 methods of skin and nail preparation were compared in terms of their efficacy in eliminating bacteria from the hallux nailfold and first web space of the normal foot in 28 healthy adult volunteers. Efficacy was determined by evaluating the difference in the total bacterial load before and after skin preparation. The foot-preparation solutions evaluated were 4% chlorhexidine gluconate, 70% isopropyl alcohol, and 7.5% to 10% povidone-iodine.

RESULTS: The addition of alcohol to povidone-iodine was found to increase the efficacy of the preparation method. The nailfold remained contaminated after any of the preoperative skin- and nail-preparation methods studied.

LIMITATIONS: This study did not measure clinically relevant infections, and the results may not correlate with decreased rates of infection after surgery.

CONCLUSION: Incorporation of alcohol and povidone-iodine into the preoperative skin- and nail-preparation process may help reduce the bacterial load. Every effort should be made to lower the risk of contamination from the nail.
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NewsBot · Oct 3, 2009

Quantitative analysis of bacteria in forefoot surgery: a comparison of skin preparation techniques.
Cheng K, Robertson H, St Mart JP, Leanord A, McLeod I.
Foot Ankle Int. 2009 Oct;30(10):992-7.

BACKGROUND: Currently a lack of consensus exists on the optimum solution and preparation methods needed to decrease bacteria present during forefoot surgery. We therefore compared the effect of povidine-iodine and chlorhexidine gluconate on lowering bacterial load and to study any additional benefits gained by pre-treatment with the use of a bristled brush.

MATERIALS AND METHODS: Fifty consecutive patients undergoing forefoot surgery were recruited into the study and randomized to receive one of two surgical skin preparations (Povidine-iodine 1% with isopropyl alcohol 23% or Chlorhexidine gluconate 0.5% with isopropyl alcohol 70%). In addition to the skin preparation of the foot with the randomized solution, the subjects other foot was also scrubbed with a sterile surgical bristled brush for three minutes and then painted with the same solution. Swabs were taken from three sites and analyzed via qualitative and quantitative analysis before and after prepping.

RESULTS: All four preparation methods significantly decreased (p < 0.001), in all three sites, the number of colony forming units. Using two-way analysis of variance, no significant interaction was observed between preparation method and number of colony-forming units, suggesting that no difference in bacterial inhibition between preparation methods.

CONCLUSION: We suggest that either povidone-iodine with no more that 23% isopropyl alcohol or chlorhexidine gluconate with 70% isopropyl alcohol be used for surgical preparation in forefoot surgery. No additional benefit in reduction in bacterial load was gained by scrubbing the foot with bristles prior to painting.
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NewsBot · Jul 31, 2010

Efficacy of preoperative and intraoperative skin and nail surgical preparation of the foot in reducing bacterial load

Efficacy of preoperative and intraoperative skin and nail surgical preparation of the foot in reducing bacterial load.
Becerro DE Bengoa Vallejo R, Losa Iglesias ME, Alou Cervera L, Fernández DS, Prieto JP.
Dermatol Surg. 2010 Aug;36(8):1258-65.

BACKGROUND A common problem associated with toenail removal surgery is the accompanying bacterial infection that often ensues. The foot has a particularly difficult anatomy to prepare antiseptically for surgery, which contributes to this wide-spread problem.

OBJECTIVE To compare the antiseptic efficacy of two skin pretreatment methods before toenail avulsion surgery.

METHODS Two presurgical methods were performed on 24 patients each (48 patients total). Swab samples were taken from each patient at five distinct stages (pretreatment, post-treatment, after surgery, after saline solution irrigation of the nail bed, and after phenol application) throughout the surgical procedure, and bacterial culture analysis was performed (total inocula count and identification of specific microorganisms).

RESULTS We found both methods to be effective at reducing the initial bacterial load when used at pretreatment, but the reduction in bacterial load was lost after the nail avulsion surgery, achieving values similar to the initial bacterial load before the presurgical scrub, from 5.17 and 5.04 log(10) colony-forming units (CFU)/cm(2) to 4.86 and 5.07 log(10) CFU/cm(2), respectively. An interoperative irrigation step was effective in reducing the bacterial load by 95.2% and 95.3%, respectively.

STUDY LIMITATIONS Our patients underwent phenol-based nail avulsion, resulting in no bacterial load after complete nail removal because of the intrinsic antiseptic nature of the phenol. CONCLUSIONS Incorporation of intraoperative irrigation of sterile saline solution after nail avulsion surgery reduces potential bacterial load. Every effort should be made to lower the risk of contamination after nail plate avulsion. The authors have indicated no significant interest with commercial supporters.
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Paul_UK · Sep 13, 2010

Does anyone have these in full articles? My athens account doesnt't give me access to them.

mgates01 · Sep 13, 2010

Hi Paul
here's the one above
Michael

Paul_UK · Sep 14, 2010

Thanks Michael thats great!

sarahboss · Jun 21, 2011

does anybody have any information on skin cleansing and its effetiveness?

Bethy · Oct 4, 2012

Does anybody know of an alternative to iodine as a pre-operative swab for nail avulsion available in Australia? I have a patient with an iodine allergy who requires partial nail avulsion? Thanks

Beth

Lovefeet · Oct 4, 2012

Bethy, if you don't get a reply from anyone on this site, try contacting the theatre at a hospital. The theatre staff should be able to help you. Wouldn't mind knowing the answer me self....Good luck!!

NewsBot · Jan 19, 2013

Comparison of the effectiveness in bacterial decontamination between chlorhexidine gluconate and povidone-iodine solution in foot and ankle: a pilot study.
Rugpolmuang L, Thanabodeethada R, Riansuwan K.
J Med Assoc Thai. 2012 Sep;95 Suppl 9:S95-8.

BACKGROUND:
The decontamination for foot and ankle surgery should be considered as a special preparation due to higher rate of bacterial contamination. The footwear and humidity is also the issue of interest especially in tropical country. The contamination before surgery should be reduced to avoid the infection. The effectiveness of antiseptics and special condition for the foot and ankle surgery should be elucidated for better medical care.

MATERIAL AND METHOD:
The twenty volunteers were included in the present study. In group 1, the foot was scrubbed with 7.5% Povidone-lodine and painted with 10% Povidone-lodine solution. In group II, the foot was scrubbed with Chlorhexidine gluconate scrub and painted with 2% Chlorhexidine gluconate in 70% alcohol. At the beginning and end of the preparation, specimens were taking from all toes, nailfold, interdigital web spaces. These samples were sent for aerobic bacterial cultures. The results were interpreted as positive or negative cultivation and the number of bacterial colonies.

RESULTS:
All of the samples from 40 feet were collected; In Group I, positive culture was 5 samples (25%). In Group II, positive culture was 2 samples (10%) (p = 0.2).

CONCLUSION:
The Chlorhexidine gluconate and Povidone-lodine are effective in reduction the number of bacterial colonization. The steps of preparation before surgery also play an important role in eliminating the pathogenic bacteria. Both antiseptics were found no significant different in efficacy of pathogenic bacteria reduction.
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NewsBot · May 11, 2013

Efficacy of preparation solutions and cleansing techniques on contamination of the skin in foot and ankle surgery: A systematic review and meta-analysis.
Yammine K, Harvey A.
Bone Joint J. 2013 Apr;95(4):498-503.

We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001). Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S&P) followed by alcohol showed significantly better efficacy over PI (S&P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S&P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.
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NewsBot · Jun 1, 2016

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?
Bhaveen H. Kapadia, Peter L. Zhou, Julio J. Jauregui, Michael A. Mont
Symposium: Proceedings Of The 2015 Musculoskeletal Infection Society; Clinical Orthopaedics and Related Research; July 2016, Volume 474, Issue 7, pp 1592-1598

Background
Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size.
Questions/purposes
(1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol?
Methods
In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category.
Results
Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9–20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1–60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5–9.6; p = 0.33] and RR, 11.3 [CI, 0.7–186.7; p = 0.09]).
Conclusions
A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study.
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NewsBot · Jan 3, 2019

Chlorhexidine 0.5%/70% Alcohol and Iodine 1%/70% Alcohol Both Reduce Bacterial Load in Clean Foot Surgery: A Randomized, Controlled Trial
Marwan B. Shadid et al
JFAS: January 03, 2019

No consensus exists regarding which cleansing technique, solution, and concentration should be used in orthopedic surgery. The aim of this randomized, controlled trial was to compare the effect of chlorhexidine 0.5%/70% alcohol with iodine 1%/70% alcohol on lowering positive cultures before elective foot surgery and to study any wound complications, infections and allergic reactions. Consecutive patients ≥18 years of age scheduled for a hallux valgus correction or arthrodesis of the first metatarsophalangeal joint were included. Swabs were taken from 2 sites before and twice after preparing the skin and were quantitatively and qualitatively analyzed. The study group consisted of 49 patients with a mean age of 52.3 ± 14.4 (range 22 to 75) years of whom 42 (86%) were female. No significant differences were observed for positive cultures between the chlorhexidine (73%, 2%, and 12%) and iodine (68%, 7%, and 9%) group at any time point. Coagulase-negative staphylococci were the most commonly isolated micro-organisms found after skin preparation. Occasionally, Bacillus spp and Corynebacterium spp were cultured. The complication rate 2 weeks postoperatively was 0% in the chlorhexidine group versus 8.7% (n = 2) in the iodine group (delayed wound healing; p = .215). The complication rate at 6 weeks postoperatively was, respectively, 3.8% (n = 1) versus 4.3% (n = 1; both showed swelling and redness; p > .999). There was no significant difference in postoperative wound problems or infection rates between the 2 skin preparation solutions. Chlorhexidine 0.5%/70% alcohol and iodine 1%/70% alcohol both decreased the amount of positive cultures in elective foot surgery.
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NewsBot · Jul 21, 2021

Randomized Trial of Dilute Povidone-Iodine Soak and Scrub for Orthopedic Foot and Ankle Surgery
Nasima Mehraban et al
Foot Ankle Int. 2021 Jul 20;10711007211025263.

Background: There is no consensus as to which skin antiseptic solution is most effective at reducing infection following orthopedic foot and ankle surgery. The purpose of this study is to determine if the addition of a dilute povidone-iodine soak and scrub to a standard preparation with alcohol and chlorhexidine decreases positive bacterial culture rates from the hallux nailfold.

Methods: In this prospective, randomized controlled trial, 242 subjects undergoing orthopedic foot and ankle surgery were randomized to one of 2 groups. The control group received our standard 2-step skin antiseptic preparation of an alcohol scrub (step 1) followed by chlorhexidine/alcohol paint (step 2). The intervention group received a 3-minute dilute povidone-iodine soak and scrub followed by that same standard 2-step skin preparation. Immediately before skin incision, culture swabs were taken from the hallux nailfold of both groups.

Results: Of the 257 subjects enrolled and randomized, 242 (94.2%) completed the study, satisfying the a priori sample size requirement of 242 subjects. There were no crossovers between groups. There were no differences in baseline characteristics between groups (P > .05 for each). There was no difference in bacterial growth rates between groups (26.8% growth in the intervention group vs 26.9% growth in the control group, P = .991).

Conclusion: The hallux nailfold is one of the most difficult to sterilize areas prior to orthopedic foot and ankle surgery. This randomized controlled trail found no benefit to adding a 3-minute dilute povidone-iodine soak and scrub to a standard skin preparation with alcohol and chlorohexidine.
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NewsBot · Nov 22, 2022

Surgical Site Infection after Foot and Ankle Surgery: A Retrospective Analysis of Incidence using a Low Concentration Chlorhexidine Gluconate (CHG) 0.05% in Sterile Water
Calvin J. Rushing, DPM et al
Source

Introduction/Purpose:
Surgical site infection (SSI) after foot and ankle procedures adversely impacts both the quality and cost of health care delivery; increasing hospital length of stay, the number of re-operations, and readmission rate(s). The purpose of the present study was to assess the incidence of SSI in patients who underwent foot and ankle surgery with concurrent intraoperative lavage containing low concentration Chlorhexidine Gluconate (CHG) 0.05% in sterile water.
Methods:
Seventy-three patients underwent reconstructive foot and ankle procedures which utilized low concentration CHG 0.05% for intraoperative lavage between September 2020 and October 2021, at a single institution. Minimum follow-up for inclusion was at least 90 days; procedures with concurrent use of topical vancomycin powder, or prophylactic antibiotics postoperatively were excluded. Demographic data, and the incidence of complications including postoperative erythema, delayed wound healing, dehiscence, SSI, as well as reoperations were recorded. Univariate and multivariate analyses were performed.
Results:
Twelve complications occurred in 73 patients (16%): 1 erythema (1.4%), 4 delayed wound healing (5.5%), 1 dehiscence (1.4%), and 6 SSI's (8.2%). Of the 6 SSIs, 2 were superficial and 4 deep; representing an incidence rate of 2.7 and 5.5%, respectfully. Six reoperations were performed in 4 patients for deep SSI; 3 (75%) had a previously documented history of SSI after orthopedic surgery. A history of previous SSI infection after orthopedic surgery was identified as an independent predictor of future SSI following foot and ankle surgery (p <.05). No associations were identified for purported risk factors.
Conclusion:
The present study is the first to assess the utility of a low concentration CHG 0.05% as an intraoperative irrigation agent for the purpose of mitigating postoperative SSI after foot and ankle surgery. The data suggests a low incidence of deep SSI in patients without a documented history of previous SSI after orthopedic surgery; without the concurrent use of topical vancomycin or prophyaltic antibitiocs, postoperatively. Additional studies are warranted to better understand the potential association identified.
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NewsBot · Nov 2, 2023

Comparing the efficacy of chlorhexidine and povidone–iodine in preventing surgical site infections: A systematic review and meta-analysis
Dunyao Bai, Fan Zhou, Liuting Wu
Source

Surgical site infections (SSIs) post-surgery impact patient health and raise healthcare costs. This meta-analysis examines the efficacy of antiseptics, chlorhexidine and povidone–iodine, in reducing SSIs, including various types, to settle ongoing debates on their comparative effectiveness. A systematic literature search conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was executed on four established databases without temporal restrictions. Only randomized controlled trials (RCTs) including patients aged 18 years or older undergoing clean or potentially contaminated surgeries were included. Two independent evaluators carried out study selection, data extraction and quality assessment, adhering to Cochrane Collaboration's risk of bias tool. Statistical analyses were performed using chi-square tests and the I2 index to evaluate heterogeneity, and meta-analyses were conducted employing either fixed-effects or random-effects models as warranted by the heterogeneity assessments. A total of 16 RCTs were included after rigorous selection from an initial pool of 1742 articles. The studies demonstrated low levels of heterogeneity, supporting the use of a fixed-effects model. Chlorhexidine exhibited statistically lower rates of overall SSIs (RR 0.75; 95% CI 0.64–0.88; p < 0.001), superficial SSIs (RR 0.62; 95% CI 0.47–0.82; p < 0.001) and deep SSIs compared to povidone–iodine. The study furnishes compelling evidence in favour of chlorhexidine as a more efficacious antiseptic agent over povidone–iodine in minimizing the risk of various types of SSIs.
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Evidence base of pre-op skin preparation

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Efficacy of Preoperative and Intraoperative Skin and Nail.pdf

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Evidence base of pre-op skin preparation

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