1. Evidence Based Practice Regarding Chlorhexidine Use to Prevent Surgical Site Infection
Presented by:
Cindy Magirl
Eric Nelson
Tennille Sassano
Jennifer Vicarie

2. What does the literature say about the use of Chlorhexidine in the prevention of surgical site infections (SSI’s)?

4. It is estimated that between 750,000 and 1 million SSIs occur in the United States each year (Edmiston et al., 2010).
SSIs remains a substantial cause of post-operative morbidity and increased health care costs (Riley et al., 2012).
SSIs result in 3.7 million additional hospital days and $845 million spent nationally. (Zinn et al., 2010)

5. The aim is to evaluate the effectiveness of evidence-based prevention and control strategies to reduce rates of SSIs.

6. Procedural (extrinsic)
TABLE 1. Selected Patient and Procedural Characteristics Associated With Increased Risk of Surgical Site Infections
Patient (intrinsic)
Procedural (extrinsic)
Age
Diabetes (metabolic disease)
Perioperative hyperglycemia
Tobacco use
Concurrent infection (distant)
Obesity
Malnutrition
Immunocompromise
Low preoperative serum albumin level
Corticosteroid use
Prolonged hospitalization before surgery
Prior radiation to surgical field tissue
Staphylococcus aureus colinization
Lack of preoperative shower
Site shaving the night before surgery
Extended operative time
Flawed skin antisepsis
Flawed surgical prophylaxis
Effects of the OR environment (eg, hypothermia)
Break in aseptic technique
Hypothermia or hypoxia
Perioperative blood transfusion
Surgical technique
Hemostasis
Tissue trauma
Edmiston et al., 2010

7. Surgical Studies
1978 – study showed that application of CHG to the skin surface resulted in a greater microbial log reduction and it persisted several hours after application compared with povidone iodine
1988 – documentation shows that repeat application of CHG 4% was superior to a single shower in reducing staphylococcal skin contamination
Edmiston et al., 2010

8. Total Joint Replacement Surgical Study
PRE-INTERVENTION GROUP
POST-INTERVENTION GROUP
727 patients
Self bathing of povidone iodine night prior to surgery
After 3 months, 3.19% infection rate
737 patients
Self bathing of CHG 2% impregnated polyester cloths night prior to surgery and staff assisted bath on admission to hospital
After 3 months, 1.59% infection rate
Edmiston et al., 2010

9. Appraisal
Overall the evidence is strong in supporting the use of CHG. In the journal article, the authors identify some weakness within the studies they included. For example, in one of the studies the author lists several problematic issues involving study design, implementation, and analysis. Another weakness of this literature review is several studies were included and because of this, there was a lot of pertinent information left out in order to summarize the amount of information.

10. Low Transverse Cesarean Section (LTCS) Surgical Study Time Line
Baseline Period (October, March, 2006) SSI rate retrospective identification for comparison
Riley et al., 2012

11. Low Transverse Cesarean Section (LTCS) Surgical Study Time Line
Outbreak Period
(April, 2006 – October, 2006)
Obstetrics and gynecology (OBGYN) clinicians noticed an increase in post-LTCS patients returning with SSI in 2006
Focused on identifying critical control points and analyzing hazards by directly observing LTCS procedures
Labor and delivery (L&D) operating room (OR) walks
Self administered employee survey
Limited personnel traffic during surgery
Improved surgical hand scrub
Modified surgical skin preparation
Changed the timing of antimicrobial prophylaxis
Revised L&D OR policies
Performed SSI prevention in-services
Completed employee competency training

12. Low Transverse Cesarean Section (LTCS) Surgical Study Time Line
Intervention One Period
(November, 2006 – September, 2007)
Focused on changing practice and fully implementing all recommendations from outbreak period
Fully implemented recommendations based on the CDC’s SSI prevention guidelines

13. Low Transverse Cesarean Section (LTCS) Surgical Study Time Line
Intervention Two Period
(October, December, 2008)
Chloroprep, a combination of 2% CHG and 70% isopropyl alcohol (IPA) replaced povidone-iodine for surgical skin prep
Implementation of preoperative CHG skin cleansing program
Scheduled – patient performed night before surgery
Unscheduled – nurse performed as part of presurgery prep
Moved into new hospital building
Changed administration time of antibiotic
Nurses in OBGYN clinics educated patients about SSI prevention

14. Appraisal
Evidence in itself was strong based on the reduction of SSIs during the study. However, there were also several limitations to the study:
Implementation of multiple interventions at the same time. Which intervention was successful?
Cost analysis was not studied in depth.
Although patients were instructed to contact their physician for signs and symptoms of infection, no official follow-up was coordinated.

15. Inraoperative Patient Skin Prep Agents: Is There a Difference?
The authors conducted an article review to evaluate if there is a superior intraoperatvie prep available for open abdominal and general surgery procedures. The authors concluded that there is no one prep that is superior in all situations. (Zinn et al.,2010)

16. Comparison of Prep Solutions
Providine-iodine
Chlorexidine
Advantages
Excellent gram-positive activity
Good gram-negative activity
Broad spectrum
Moderate rapidly of action
Long established as an effective agent
Advantages
Excellent gram-positive activity
Good gram-negative activity
Broad spectrum
Moderate rapidly of action
Excellent persistent and residual activity

17. Comparison of Prep Solutions
Providone- iodine
Chlorhexidine
Disadvantages
Minimal persistence and residual activity
Decreased effectiveness in the presence of blood and organic material
Lack of recent empirical evidence
Disadvantages
Contraindicated for use on eyes, ears, brain and spinal tissue, genitalia, mucus membranes
Inactivity in the presence of saline solution
Drying effect on the skin

18. Appraisal Only 29 studies were involved in this literature review
Each prep agent has specific advantages and disadvantages.
The study reviewed several prep agents because of the considerations for patient allergies, natural flora, surgical site, and surgeon preference.
The study did not include any research of ChloraPrep
The researchers stated that they did not find adequate information to prove one prep agent used exclusively.
The article was easy to read however lacked specific information or statistical evidence; leaving a lot of unanswered questions.