The study was based on critical analysis and review of literature in evaluating the supremacy of skin preparation antiseptic between chlohexidine and povidone-iodine. Chlorhexidine gluconate can reduce the risk for catheter-related bloodstream infection by approximately 50% and should be used in preference as an preoperative antiseptic agent in clean-contaminated surgery in decreasing postoperative SSI. This study demonstrated ChloraPrep solution good value for money as its use for skin antisepsis with its significant per patient cost savings.Finally chlorhexidine gluconate is superior to povidone-iodine for preoperative antisepsis for patients. The study recommends that 2% Chlorhexidine and 70% alcohol be routinely used for the insertion of all indwelling devices such as CVCs, pacing wires, nephrostomies, and for the taking of all blood cultures.
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INTRODUCTION
Surgical-site infection (SSI) increases morbidity, mortality, duration of hospital stay and expense after surgical procedures. The patient is recognized as endogenous reservoir for infections, especially Surgical -site infection; however, this same patient is the main focus for a disease free outcome .Skin preparation is defined as preparing the patient’s skin as bacteria free as possible through shaving, physical washing and chemical disinfection to reduce the number of microbes in the operative field of operation and thus prevent infection.
Skin preparation should be done in a manner that protects and preserves integrity of the skin and prevents skin injury . Patient skin preparation which includes but not limited to , skin condition at surgical site, hair removal, skin preparation antiseptic used and any hypersensitivity reactions should be documented in the patient record according to the AORN Recommended practices for documentation of perioperative nursing care. This documentation helps in continuous quality improvement and follow-up of infection control.
An effective skin-preparation solution is a vital step in preventing the surgical wound seeding with bacteria and ultimately preventing infection. Preoperative skin antisepsis is based on the information that a patient’s skin is a significant source of microbes. Povidone-iodine and chlorhexidine both destroy bacterial and structural integrity and have been studied more extensively.However the preferred preoperative skin preparation antiseptic agent is still unknown.
METHODS
This paper will be descriptive in nature as it tries to analyze the above clinical topic. Qualitative analysis provides a qualitative data that can be utilized to compare relatively and analyze the most effective choice of skin preparation antiseptic agent between povidone iodine and chlorhexidine . The source of information is through a review of various literature’s and recent article’s in relation to the above topic. This report will aim at providing an overview on the key aspects behind the choice of the preferred skin preparation antiseptic between chlorhexidine and povidone iodine based on the data gathered from the rich data base of various studies conducted. The report also aims at identifying drawbacks and shortcomings in various research studies based on the topic.
ANALYSIS
Perioperative is the term which includes preoperative, intraoperative, and postoperative phases in the surgical episode of care. As RL Nichols, MD, states, “The critical factors in postoperative infection prevention although difficult to be quantified, are the proper technique and sound judgment of the surgeon and surgical team, as well as the general health and disease state of the patient.” This statement summarizes the importance of the perioperative team’s relationship with the patient to ensure a disease-free outcome in the postoperative period.
Healthcare is a dynamic ever changing science spiraling toward innovative technologies and interventions. The field of antiseptics is progressive with a system approach to gain an even better response in de-colonization of the skin while maintaining skin integrity. Preoperative skin preparation is performed to reduce the risk of postoperative wound infections. An ideal agent would destroy all bacteria, fungi, viruses, protozoa, and spores, non-toxic, hypo-allergenic, safe to use ,non-absorbable and have residual antiseptic activity(Hardin and Nichols 1997). The FDA further defines “patient preoperative skin preparations” as a rapid-acting, broad-spectrum, persistent antiseptic-containing preparation that significantly decreases the microbes on intact skin.
An antiseptic should be selected based on certain criteria . Historically, antiseptic agents progressed from the age of alcohol and phenol to hexachlorophene, then povidone iodine followed by chlorhexidine gluconate agents with each agent having a distinct advantage. Now newer formulations offer an prolonged, enhanced and persistent efficacy with focus on patient safety. Product evaluation remains a vital process for selection of an antiseptic agent.
Chlorhexidine as the choice of Skin preparation Antiseptic
Chlorhexidine is a skin preparation antiseptic agent that has been used worldwide since 1954. It has a great track record of efficacy an safety in providing a disease free environment. Its applications are as diverse as hand wash, skin preparation(preoperative), vaginal preparation, gingivitis treatment and in baby shower to reduce incidence of neonatal sepsis. Chlorhexidine gluconate is a biguanide, water-soluble that binds to the negatively charged cell wall of bacteria, altering osmotic equilibrium of the bacterial cell. It is available commercially at a range of concentrations between 0.5%-4% and in combination with and without isopropyl alcohol .
Role of Chlorhexidine in clean-contaminated surgery in relative to Povidone iodine
A meta-analysis clinical trials by Noorani et al.,2010 was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone-iodine reduced surgical-site infection in clean-contaminated surgery. The review involved six eligible studies with a database of 5031 patients. The validity of the study was under threat by heterogeneity which was assessed using Cochran’sQ test. Chlorhexidine reduced postoperative surgical-site infection compared to povidone-iodine with a odds ratio of 0·68at a 95% confidence interval between 0·50 to 0·94,P=0.019.
This inferred that Chlorhexidine should be used in preference as an preoperative antiseptic agent in clean-contaminated surgery in decreasing Postoperative SSI.
The prospective study of about 150 patients undergoing Shoulder surgery by Saltzmann et al., 2009 found ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol; Enturia, El Paso,Texas) to be more effective than both DuraPrep(0.7% iodophor and 74% isopropyl alcohol;3M Healthcare) and povidone-iodine at eliminating overall bacteria in particular coagulase negative staphylococcus.
Propionibacterium acnes was cultured from 15% of the shoulders prepared with povidone-iodine, 12% of those with DuraPrep, and 7% of those prepared with ChloraPrep. The above results are in agreement with other studies by Malbach(1988) and Ostrander et al.,(2005) that have found the combination of chlorhexidine and alcohol to be highly effective .
Role of Chlorhexidine in catheter -site care in relative to Povidone iodine
Chaiyakunapruk et al .,2002 conducted a meta-analysis comparing chlorhexidine
gluconate with povidone-iodine solutions for catheter site care. The above study to be included in the meta-analysis needed,
1) to be a randomized trial
2) to report the incidence of catheter-related bloodstream infection with sufficient data .
They performed a meta-analysis of all available published and unpublished studies comparing povidone-iodine solution with chlorhexidine gluconate for care of the vascular catheter-site . The validity of this meta-analysis was threatened by:
Publication bias, minimized by exhaustive search for published and unpublished studies in any language.
Heterogeneity.
The results of this meta -analysis may apply to most hospitalized patients in the United States and similar health care settings.However, the role of chlorhexidine gluconate in preventing catheter-related bloodstream infection can’t be addressed in patients who are catheterized for an average of longer than 10 days and the potential additional benefit of chlorhexidine gluconate when an antimicrobial catheter is used (40, 41).
The summary risk reduction for catheter-related bloodstream infection in the main analysis and the sensitivity analyses suggests that chlorhexidine gluconate solution reduces the risk for catheter-related bloodstream infection by approximately 50%.
The superiority of chlorhexidine gluconate for catheter- site care has several potential explanations:
Firstly blood, serum, and other protein-rich substances can deactivate the microbicidal effect of povidone-iodine (9,10) but not chlorhexidine gluconate (11,12).
Second, the residual effect of chlorhexidine gluconate, defined as the long-term antimicrobial suppressive activity, is prolonged (at least 6 hours) (13,14), while that of povidone-iodine is minimal (15).
The superiority of chlorhexidine gluconate compared with povidone iodine in reducing the coagulase-negative staphylococci colony counts has been earlier shown in a study of disinfection of catheter sites in peritoneal dialsis (16).
Because most vascular catheter-related infections are caused by gram-positive cocci, the superior bactericidal effect of chlorhexidine gluconate against these organisms is likely to be clinically important.
The use of chlorhexidine gluconate rather than povidone-iodine can reduce the risk for catheter-related bloodstream infection by approximately 50% in hospitalized patients who require short-term catheterization.
It is absorbed poorly through clean adult skin which is intact and not damaged.
The combination of chlorhexidine an intranasal mupirocin baths has been shown to reduce hospital acquired MRSA infection among ICU patients [8].
is non- flammable
demonstrated as good value for money as the use of ChloraPrep for skin antisepsis in has shown reduced infection rates and cost .
Chlorhexidine has broad spectrum against both gram-positive and gram-negative bacteria, yeasts ,anaerobes and aerobes, and some enveloped viruses, including HIV .
Chlorhexidine-based antiseptic preparations are more effective than iodophors in reducing the bacterial concentration in the operative field for foot-and-ankle surgery and vaginal hysterectomy.
Chlorhexidine gluconate with Isopropyl alcohol
Isopropyl alcohol is an extremely effective bactericidal agent that, in concentrations of 70% to 90%, disorganizes cell membrane lipids and denatures cellular proteins resulting in loss of their function. Both ChloraPrep and DuraPrep contain isopropyl alcohol and were more effective than povidone iodine at eliminating bacteria from the axillary region in the prospective study by Saltzmann et al.,2009.
Ostrander et al. found fewer bacteria on feet prepared with ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol; Medi-Flex, Overland Park, Kansas) than on those prepared with DuraPrep (0.7% iodin and 74% isopropyl alcohol; 3M Healthcare, St. Paul, Minnesota) or Techni-Care (3.0% chloroxylenol; Care-Tech Laboratories, St. Louis, Missouri) as the use of a combination of chlorhexidine gluconate and alcohol is perhaps a way to take advantage of their antiseptic properties. The low surface tension of isopropyl alcohol assists in penetration of irregular contours such as the axilla more effectively than other agents (6,7).
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The Cost factor for chllorhexidine
Kelly et al.,2005 identified decreased infection rates with the use of ChloraPrep compared to chlorhexidene 0.5% and povidone iodine 10%. Thus the ChloraPrep solution for antisepsis also resulted in significant per patient cost savings relative to the 10% povidone-iodine(714£) and 0.5% chlorhexidene solution(254£).This study demonstrated ChloraPrep value for money as its use for skin antisepsis in a UK ITU population resulted in reduced infection rates and cost .
Issues against Chlorhexidine as Skin preparation Antiseptic
Based on the meta-analysis by Chaiyakunapruk et al (2002), additional issues should be considered regarding the use of chlorhexidine gluconate for catheter-site care :
Hypersensitivity reactions including potential side effects such as increased erythema have been reported with use of central venous catheters and with use of chlorhexidine gluconate for pre-operative showers (17-21).
Bacterial resistance is another potential concern, but is negligible despite its widespread use for several decades.
The role of chlorhexidine gluconate in preventing catheter-related bloodstream infection in patients who are catheterized for longer duration(<10 days) is still under the cloud.
The potential additional benefit of chlorhexidine gluconate is unexplained when an antimicrobial catheter is used (22,23).
the higher cost of chlorhexidine gluconate. However, although chlorhexidine is approximately twice as expensive as povidone-iodine, the absolute difference is relatively small .
Inner ear contact may result in permanent deafness .
Direct application of chlorhexidine on neural tissue in a rat specimen caused degeneration of adrenergic nerves .Thus, chlorhexidine for skin preparation before epidural catheters insertion, has been avoided for fear of damage to neural tissue.
chlorhexidine products have not been established safe for use in children.
It is non- sporicidal
Povidone Iodine as the choice of Skin preparation Antiseptic
Iodophors are effective against a wide range of bacteria and spores. The mode of action is by penetration of the cell wall and the oxidation and replacement of intracellular molecules with free iodine (Hardin and Nichols 1997). Iodophors are solutions of iodine with a stabilizing agent that releases free iodine (Department of Pharmacological Sciences 1980).
Role of Povidone Iodine as Skin preparation Antiseptic
There is a significant reduction in the bacterial count in the povidone iodine-ethanol group compared to chlorhexidine gluconate-ethanol group immediately after washing .
Equally effective among skin antiseptics used in clean surgery.
Most widely used antiseptic agents for surgical scrubbing .
Rapidly acting antiseptic agent.
Oldest antiseptic agent and hence widely available.
Cost effective, cheap and easily available.
Issues against Povidone Iodine as Skin preparation Antiseptic
Cooper et al., evaluated the toxicity of common wound irrigants with use of a proven cell-viability assay and found povidone-iodine, even to be extremely toxic to fibroblasts and keratinocytes in concentrations of 0.5% (1/20th) of those used in clinical practice.
The current article by Fletcher et al., 2007 synthesizes the best available evidence regarding use of
preoperative skin preparation of the patient and surgeon in the hope that it will help physicians to reduce the incidence of postoperative wound infection. On an Overview Fletcher et al reviewed the best available literature in an attempt to help orthopedic surgeons to minimize surgical site infections in their patients and made the best possible recommendation below.
The iodophors also act against common skin flora; however, their activity is much shorter than that of chlorhexidine gluconate.
The effect of povidone-iodine is sustained for a shorter duration in skin in relative to chlorhexidine.
The iodophors can be inactivated by blood or serum proteins and should be allowed to dry in order to maximize their antimicrobial action.
In vitro studies by Cooper et al , have provided strong evidence that povidone-iodine may impair wound-healing and hence povidone-iodine should not be used for preparation of open wounds or on postoperative dressings
A recent meta-analysis showed no difference in efficacy between chlorhexidine and povidone iodine; however, the rarity of infection in such situations probably explains the low power of the included studies.
Based on the current literature review by Fletcher et al.,2007 published by The Journal of Bone and Joint surgery strongly suggests that chlorhexidine gluconate is superior to povidone-iodine for preoperative antisepsis for patients.
Methicillin-resistant Staphylococcus aureus (MRSA)
The spread of multidrug-resistant organisms particularly methicillin-resistant Staphylococcus aureus (MRSA) in hospitals has become a major viewpoint, especially as community-associated MRSA strains have been a major cause of hospital acquired infections. It can be identified by skin culture in 8%-44% of patients admitted to the intensive care unit .
A study by University Hospital Birmingham NHS Foundation Trust was conducted to measure the impact of using ChlorPrep on the incidence of MRSA bacteraemia after the insertion of pacing wires,Central venous catheter’s and nephrostomies. The study found a numerical reduction of MRSA bacteraemia over the one-year study period which remained sustained.
CONCLUSION
Based on the benefit and small incremental cost, chlorhexidine gluconate should be considered as a replacement for povidone-iodine solution, particularly in patients at high risk for catheter related bloodstream infection. It can reduces the risk for catheter-related bloodstream infection by approximately 50%. Chlorhexidine should be used in preference as an preoperative antiseptic agent in clean-contaminated surgery in decreasing Postoperative SSI. The use of a combination of chlorhexidine gluconate and alcohol is perhaps a way to take advantage of their antiseptic properties..This study demonstrated ChloraPrep solution good value for money as its use for skin antisepsis with its significant per patient cost savings.
Although povidone -Iodine is equally effective among skin antiseptics used in clean surgery, the effect of povidone-iodine is sustained for a shorter duration and can be inactivated by blood or serum proteins. Povidone-iodine may impair wound healing and hence avoided in open wound preparation and postoperative surgeries. Finally chlorhexidine gluconate is superior to povidone-iodine for preoperative antisepsis for patients.
RECOMMENDATIONS
The Centers for Disease Control and Prevention (CDC) recommends that patients have a shower with an antiseptic on the night before surgery and to be applied to the skin at the site of incision.
The Birmingham NHS Foundation Trust recommends that ChlorPrep(2% Chlorhexidine and 70% alcohol )be routinely used for all indwelling devices including CVCs, pacing wires, venipuncture and nephrostomies
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