ABSTRACT:

OBJECTIVE To compare antisepsis techniques using chlorhexidine-based soap associated with ethyl alcohol and alcohol-based chlorhexidine or chlorhexidine-based soap associated with alcohol-based chlorhexidine alone in surgical orthopedic procedures.
METHODS This is a primary, randomized, analytical and single-center clinical trial consisting of 170 patients, who were divided into 2 groups. The combinations chlorhexidine-based soap + alcohol-based chlorhexidine (CSAC) and chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine (CSAAC) were tested in each group. The cultures were grown in mannitol and eosin methylene blue (EMB) after collection before skin preparation (time point 0), after skin preparation (time point 1) and at the end of the surgical procedure (time point 2).
RESULTS There was no statistically significant difference regarding bacterial growth in mannitol and EMB between the groups at any time point. Moreover, there was no statistical difference between groups and time points regarding the type of bacterial growth in culture media.
CONCLUSION There was no difference between these antisepsis techniques for the prevention of surgical site infection in orthopedic procedures; in addition, a protocol containing measures to prevent infection in such procedures was developed.

Keywords: chlorhexidine; infection; orthopedics; operating rooms; antisepsis; surgical procedures.

RESUMO:

OBJETIVO Comparar as técnicas de antissepsia utilizando clorexidina degermante associada a álcool etílico e a clorexidina alcoólica versus clorexidina degermante associada a clorexidina alcoólica, em procedimentos cirúrgicos ortopédicos.
MÉTODOS Trata-se de um estudo clínico, primário, randomizado, analítico e de centro único, constituído por 170 pacientes ortopédicos submetidos a abordagem cirúrgica, alocados em 2 grupos aleatórios, nos quais foram testados clorexidina degermante + clorexidina alcoólica (grupo CDCA) e clorexidina degermante + álcool etílico a 70% + clorexidina alcoólica (grupo CDACA). Foram realizadas culturas nos meios manitol e eosina azul de metileno (EAM) de amostras colhidas nos períodos de pré-degermação (0), pós-degermação (1) e após a incisão suturada (2).
RESULTADOS Em relação ao crescimento bacteriano nos meios de cultura manitol e EAM entre os grupos, em cada período de estudo (0, 1 e 2), não ocorreu diferença estatística significativa nesta pesquisa. Na avaliação do tipo de crescimento bacteriano nos meios de cultura manitol e EAM, também não foi constatada significância estatística entre os grupos.
CONCLUSÃO Não ocorreu diferença entre as técnicas utilizadas na antissepsia para prevenção de infecção de sítio cirúrgico em procedimentos ortopédicos, mas, ao final do trabalho, foi possível a elaboração de um protocolo de medidas para realização de prevenção infecciosa nesses procedimentos.

Palavras-chave: clorexidina; infecção; ortopedia; salas cirúrgicas; antissepsia; procedimentos cirúrgicos.

FIGURES

Citation: Mendes EC, Carvalho MC, Carvalho RB, Ferraz CA, Souza DMS, Schnaider TB. Antisepsis Techniques in Orthopedic Surgical Procedures: A Comparative Study*. 55(2):156. doi:10.1055/s-0039-3400520
Note: * Study performed at Hospital das Clínicas Samuel Libânio, Pouso Alegre, MG, Brazil.
Conflict of Interests: The authors have no conflict of interests to declare.
Received: August 16 2018; Accepted: January 08 2019
 

INTRODUCTION

Surgical site infection (SSI) is among the most researched subjects, and it is frequently associated with surgical complications, affecting up to one third of patients undergoing surgical procedures in low- and middle-income countries.

Data from the Centers for Disease Control and Prevention estimates that nearly 500 thousand SSIs occur each year, representing almost a quarter of nosocomial infections in the United States annually.1

In Brazil, although there are no systematic data, SSIs are ranked third among causes of infection, being found in approximately 14% to 16% of hospitalized patients. In addition to the physical, psychological and financial damages to patients, SSI can prolong the hospital stay by an average of seven to eleven days; moreover, it increases the chances of hospital readmission and additional surgeries, resulting in an exorbitant increase in care expenses, which may reach US$ 1.6 billion per year.2,3 Literature reviews provide historical data on antisepsis, from rudimentary procedures, which are evidently far from being safe and effective, to those known today.4 In a systematic review, Lee et al5 concluded that chlorhexidine-based compounds are more effective for surgical site antisepsis than iodine, leading to a significant cost reduction.

Mears et al,6 Swenson et al,7 Saltzman et al,8 and Savage and Anderson1 were able to prove the efficacy of chlorhexidine compared with iodine. Reichel et al9 showed the effectiveness of alcohol + chlorhexidine in skin antisepsis.

It is agreed that the effectiveness of surgical preparation directly impacts the occurrence of SSIs, which depends on the antiseptic solution used and on the method of application. However, it is not clear which should be the antiseptic solution or association, the time for action, the application methodology, or the moment in which skin antisepsis should be performed. As such, the present study aims to compare the effectiveness of chlorhexidine-based soap + alcohol-based chlorhexidine (CSAC) and chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine (CSAAC) to evaluate the best way of skin preparation for orthopedic surgical procedures regarding bacterial growth and surgical time.

 

MATERIALS AND METHODS

The present is a primary, randomized, prospective, analytical, single-blinded and single-centered clinical study to compare antisepsis techniques using CSAC and CSAAC in orthopedic surgical procedures. The data were collected in the operating room and in a research laboratory from a high-complexity hospital from the Brazilian Unified Health System (Sistema Único de Saúde, SUS, in Portuguese). After approval by the Ethics in Research Committee on May 9, 2017 (under opinion number 2.054.709), the study was conducted from June to November 2017.

In total, 190 patients were selected according to the eligibility criteria, and the final sample was composed of 170 patients who would undergo orthopedic surgical procedures.

The inclusion criteria were: both male and female patients; those older than 18 years of age; patients submitted to all elective orthopedic surgical procedures; and those who signed the informed consent form (ICF). The exclusion criteria were: patients undergoing urgent/emergency surgery; patients with a known history of chlorhexidine allergy or who had any kind of skin or systemic reaction during its application; those with existing skin lesions; patients from the intensive care center; those with open fractures at the time of the initial care; and patients using external fixators for fracture stabilization. Cases of preoperative death and of loss of material were also excluded.

The patients who met the eligibility criteria were separated through a random number table generated by the website http://www.randomization.com (# 25432, May 8, 2017) into two groups: CSAC and CSAAC. The patients were properly prepared for the surgical procedure following the Health Care Infection Prevention Measures of the Brazilian Health Regulatory Agency (Agência Nacional de Vigilância Sanitária, ANVISA, in Portuguese),3 including a full-body bath two hours prior to surgery with the use of 4% chlorhexidine in those undergoing major elective surgery or receiving orthopedic implants; the patients undergoing elective minor or medium-sized surgeries used only neutral soap in the full-body bath. Patients using plaster cast immobilizations were exempted from the full-body bath, since plaster removal would cause pain and discomfort, and it is associated with risks, including fracture-related skin perforation.

At the operating room, complying with the antibiotic prophylaxis protocol, the patients received intravenous (IV) cefazolin, 2 g diluted in 250 mL of saline solution, starting 30 minutes before the procedure; next, every 8 hours, 1 g of IV cephazolin was administered for 24 hours after surgery. The preoperative blood sugar level was measured 30 minutes before the procedure and immediately after surgery. Patients who had hair at incision sites underwent a hair clipping procedure using a 3M (Maplewood, MN, US) device; disposable blades were used for each patient, according to the previously mentioned Health Care Infection Prevention Measures.3

After anesthesia, sterile swabs were used to collect samples from the patient's skin microbiota at a previously selected location in the surgical site, in a 16-cm2 area determined by a previously cut paper field sterilized at the Sterilization Center. The samples were collected at the three time points.

All samples were placed in test tubes with 1 mL of buffered phosphate solution and sent to the research laboratory, where they were cultivated on plates with mannitol or eosin methylene blue (EMB) agar media.

All test tubes containing the collected swabs and culture plates were sequentially numbered according to each patient, from 1 to 170. The time points were identified as 0, 1 and 2. The number 0 corresponds to the materials collected before skin preparation; number 1 refers to materials collected after skin preparation with 4% chlorhexidine followed by excess removal with dry gauze or gauze soaked in 70% ethyl alcohol; and number 2 refers to the materials collected at the end of surgery (Figure 1).

Fig. 1. Figures showing the time of sample collection. (A) Patient under anesthesia, with the surgical limb isolated with drapes; (B) sample collected before skin preparation; (C) skin preparation with chlorhexidine-based soap and excess removal; (D) sample collected after skin preparation; (E) sample collected at the end of the surgery, after surgical wound closure, with the patient still in the sterile environment.

In both groups, samples were collected from the surgical site before skin preparation (time point 0) with 4% chlorhexidine for 5 minutes. Any excess material was removed in a single, proximal to distal movement with a simple, sterile gauze soaked in 70% alcohol for the CSAAC group and a simple, sterile dry gauze for the CSAC group.

After skin preparation, sterile swabs were similarly used to collect samples in the previously studied area, followed by antisepsis with alcohol-based chlorhexidine and placement of surgical drapes (time point 1). At the end of the surgical procedure (after incision closure), while the patient was still at the sterile environment, a new sample was collected using the same technique at the same demarcated site (time point 2). The samples were placed separately in test tubes with 1 mL of buffered phosphate solution and sent to the laboratory for analysis.

After 48 hours of culture, the culture media were evaluated for organism growth. In case of growth, the number of colonies was counted, and Gram-positive (Staphylococcus aureus and non-aureus) and Gram-negative bacteria were identified. Samples from all time points, in both the mannitol and EMB media, were evaluated to verify if the number of colonies had decreased, increased or remained unaltered after skin preparation. In the case of growth in cultures from time point 2 (after incision closure), the plates were sealed with tape and sent to the Clinical Analysis Laboratory for sensitivity determination. Thus, all subjects were evaluated regarding the efficacy of the antisepsis, as well as the organisms growing at culture.

The data were tabulated in Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, US) spreadsheets and submitted to statistical analysis. The Chi-squared test was performed using the Statistical Package for the Social Sciences (SPSS, IBM Corp. Armonk, NY, US), version 20.0.0, with the null hypothesis rejection level set at 5% (p ≤ 0.05). The numerical variables were analyzed using descriptive statistics, calculating mean and median values.

 

RESULTS

The present study compares the skin preparation performed at the Orthopedics and Traumatology Service using a chlorhexidine-based soap plus alcohol-based chlorhexidine and a chlorhexidine-based soap plus 70% ethyl alcohol and alcohol-based chlorhexidine. In total, 170 patients were eligible to participate in the study, and they were separated into 2 groups of 85 patients each. In the first group (CSAC), skin preparation was performed with chlorhexidine-based soap + alcohol-based chlorhexidine, whereas the skin preparation of the second group (CSAAC) was performed with chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine. During material collection, four sequential plates were contaminated; these plates were handled by the same resident, which justified the coincidence. Thus, these plates were eliminated, and the patients were excluded from the study. In total, 4 patients were excluded, curiously 2 from each group; as such, the final sample consisted of 166 patients divided into 2 groups of 83 patients each.

Regarding bacterial growth in the mannitol and EMB culture media, significant differences were found between the second and third time points (1 and 2) and time point 0 (Table 1); however, due to the lack of any intervention at this time point, this finding had no relevance for the present study. There were no statistically significant differences between other time points, indicating that there was no difference in the results of the two skin preparation methods (Table 2).

Table 1. Bacterial growth in the mannitol culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1), and after incision closure (2)
Mannitol Group
CSAAC CSAC Total
n % n % n %
Time point 0- before skin preparation Negative growth 6 7.3 16 19.3 22 13.3
Positive growth 77 92.7 67 80.7 143 86.7
Total 83 100.0 83 100.0 166 100.0
Time point 1- after skin preparation Negative growth 52 62.7 43 51.8 94 57.0
Positive growth 31 37.3 40 48.2 71 43.0
Total 83 100.0 83 100.0 166 100.0
Time point 2- after incision closure Negative growth 52 62.7 51 61.4 103 62.0
Positive growth 31 37.3 32 38.6 63 38.0
Total 83 100.0 83 100.0 166 100.0

Abbreviations: CSAC, chlorhexidine-based soap + alcohol-based chlorhexidine; CSAAC chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine.

Note: There was a statistically significant difference between the groups regarding bacterial growth in the mannitol culture medium at time point 0-before skin preparation (p = 0.024). The growth rate was higher in the CSAAC group compared to the CSAC group. No statistically significant difference was observed between the groups at time points 1 (p = 0.138) and 2 (p = 0.873).

Table 1. Bacterial growth in the mannitol culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1), and after incision closure (2)
Table 2. Bacterial growth in the eosin methylene blue (EMB) culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)
EMB Group
CSAAC CSAC Total
n % n % N %
Time point 0- before skin preparation Negative growth 67 80.7 62 74.7 128 77.6
Positive growth 16 19.3 21 25.3 37 22.4
Total 83 100.0 83 100.0 165 100.0
Time point 1- after skin preparation Negative growth 77 92.7 73 88.0 149 90.3
Positive growth 6 7.3 10 12.0 16 9.7
Total 83 100.0 83 100.0 165 100.0
Time point 2- after incision closure Negative growth 75 90.4 74 89.2 149 89.8
Positive growth 8 9.6 9 10.8 17 10.2
Total 83 100.0 83 100.0 166 100.0

Abbreviations: CSAC, chlorhexidine-based soap + alcohol-based chlorhexidine; CSAAC chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine; EMB, eosin methylene blue.

Note: There was no statistically significant difference between the groups regarding bacterial growth in the EMB culture medium at time points 0 (p = 0.373), 1 (p = 0.305) and 2 (p = 0.798).

Table 2. Bacterial growth in the eosin methylene blue (EMB) culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)

The type of bacterial growth in the mannitol and EMB culture media from samples collected after incision closure did not depend on the skin preparation method (Tables 3 and 4).

Table 3. Gram-positive cocci (GPC) and Gram-negative bacilli (GNB) growth in the mannitol culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)
Bacteria Group
CSAAC CSAC Total
n % n % N %
Negative growth 49 59.1 43 51.8 92 55.4
GPC 29 35.8 31 37.4 60 36.1
GNB 2 2.4 2 2.4 4 2.4
GPC and GNB 3 3.6 7 8.4 10 6.1
Total 83 100.0 83 100.0 166 100.0

Abbreviations: CSAC, chlorhexidine-based soap + alcohol-based chlorhexidine; CSAAC chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine.

Note: There was no statistically significant difference between the groups regarding the type of bacteria (p = 0.536) after incision closure.

Table 3. Gram-positive cocci (GPC) and Gram-negative bacilli (GNB) growth in the mannitol culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)
Table 4. Gram-positive cocci (GPC) and Gram-negative bacilli (GNB) growth in the eosin methylene blue culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)
Bacteria Group
CSAAC CSAC Total
n % n % N %
Negative growth 51 61.4 52 62.6 103 62.0
GPC 26 31.3 27 32.6 53 31.9
GNB 0 .0 0 .0 0 .0
GPC and GNB 6 7.3 4 4.8 10 6.1
Total 83 100.0 83 100.0 166 100.0

Abbreviations: CSAC, chlorhexidine-based soap + alcohol-based chlorhexidine; CSAAC chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine.

Note: There was no statistically significant difference between the groups regarding the type of bacteria (p = 0.783) after incision closure.

Table 4. Gram-positive cocci (GPC) and Gram-negative bacilli (GNB) growth in the eosin methylene blue culture medium in the CSAC and CSAAC groups at each time point: before skin preparation (0), after skin preparation (1) and after incision closure (2)

Both methods of skin preparation resulted in similar bacterial colony-forming unit (CFU) values (expressed as n x10 UFC/mL) obtained in both culture media (EMB and mannitol) and at all time points (0, 1 and 2). The mean CFU values were 27.3213 × 10 CFU/mL and 27.5874 × 10 CFU/mL for the CSAC and CSAAC groups respectively (Table 5).

Table 5. Quantitative analysis of the samples in the culture media at the different time points
Time point Medium Group Mean value(x 10 CFU/mL)
Before skin preparation EMB CSAC 17.0843
CSAAC 12.1707
Total 14.6424
Mannitol CSAC 116.7590
CSAAC 133.6951
Total 125.1758
Total CSAC 66.9217
CSAAC 72.9329
Total 69.9091
After skin preparation EMB CSAC 4.9518
CSAAC 0.2317
Total 2.6061
Mannitol CSAC 21.5542
CSAAC 4.1707
Total 12.9152
Total CSAC 13.2530
CSAAC 2.2012
Total 7.7606
After incision closure EMB CSAC 0.3976
CSAAC 0.2439
Total 0.3212
Mannitol CSAC 3.1807
CSAAC 15.0122
Total 9.0606
Total CSAC 1.7892
CSAAC 7.6280
Total 4.6909
Total EMB CSAC 4.4779
CSAAC 4.2154
Total 5.8566
Mannitol CSAC 47.1647
CSAAC 50.9593
Total 49.0505
Total CSAC 27.3213
CSAAC 27.5874
Total 27.4353

Abbreviations: CFU, colony-forming units; CSAC, chlorhexidine-based soap + alcohol-based chlorhexidine; CSAAC chlorhexidine-based soap + 70% ethyl alcohol + alcohol-based chlorhexidine; EMB, eosin methylene blue.

Table 5. Quantitative analysis of the samples in the culture media at the different time points

Bacterial growth in the mannitol and EMB culture media from samples obtained at time point 2 (after incision closure) was observed in 39% of the cases. These samples were sent to the Clinical Analysis Laboratory of our institution, which identified the prevalence of Staphylococcus epidermidis (58.33%), followed by S. aureus (13.88%) (Table 6).

Table 6. Microbiological analysis of the samples obtained at time point 2 (after incision closure)
Bacterium Frequency (%)
Staphylococcus epidermidis 58.33
Staphylococcus aureus 13.88
Acinetobacter iwoffii 11.14
Staphylococcus saprophyticus 4.16
Staphylococcus warneri 4.16
Staphylococcus hominis 2.77
Staphylococcus auricularis 1.39
Staphylococcus capitis-capitis 1.39
Staphylococcus haemolyticus 1.39
Staphylococcus capitis-ureolyticus 1.39
Table 6. Microbiological analysis of the samples obtained at time point 2 (after incision closure)
 

DISCUSSION

Widerström10 evaluated the clinical importance of coagulase-negative staphylococci, particularly S. epidermidis, as a major cause of healthcare-associated infections. Its pathogenicity is favored by the natural niche in human skin, thus resulting in an opportune contamination point, which reinforces the importance of correct skin preparation.

The literature still debates the best association of antiseptic agents, as well as the method and time of application. Martínez et al11 performed the first clinical trial to compare isopropyl alcohol and chlorhexidine in isopropyl alcohol for skin preparation to prevent blood culture contamination. These authors showed that blood contamination rates were not different when isopropyl alcohol and chlorhexidine were compared.11

A review of American English and French guidelines found that there is no consensus on how antiseptics should be applied. While the American and English guidelines are unclear about skin cleansing before antiseptic application (an approach that can improve the effectiveness of the antiseptic by reducing the cutaneous amounts of bacteria and protein material), the French guidelines recommend cleansing the skin with a detergent before disinfection.12

The results of the present study do not determine which is the best antiseptic association for orthopedic patients, but data from our hospital's Infection Control Center (ICC) (Table 7) obtained at the end of the study showed a reduction in ISS prevalence in such individuals, corroborating the principle that the development and adoption of a protocol (Figure 2) can significantly lower ISS rates.

Table 7. Data from the hospital's Infection Control Center (ICC) regarding orthopedic surgeries and incidence of surgical site infections (SSIs) in 2017
Month Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total
Number of surgeries 115 101 135 139 131 146 152 129 130 124 123 136 1,561
SSI 7 4 4 3 7 3 2 1 4 1 2 2 40
% 6.1 4.0 2.96 2.16 5.34 2.05 1.32 0.78 3.08 0.81 1.63 1.47 2.64
Table 7. Data from the hospital's Infection Control Center (ICC) regarding orthopedic surgeries and incidence of surgical site infections (SSIs) in 2017
Fig. 2. Pre- and perioperative measures for infection prevention in orthopedic surgeries.
 

CONCLUSION

There was no statistical difference between skin preparation with chlorhexidine-based soap plus alcohol-based chlorhexidine or chlorhexidine-based soap plus 70% ethyl alcohol and alcohol-based chlorhexidine to prevent ISS in Orthopedics. However, the adoption of a pre-, peri- and postoperative protocol is effective in reducing SSI rates.

Further studies, with larger samples, may present more details regarding the best method for the application of antiseptics. Thus, the best agent and application method continue to be discussed.

 

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