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Several evidenced-based strategies for preventing surgical-site infections (SSIs) — for example, timely perioperative antibiotic use, clipping rather than shaving for hair removal, and maintaining normothermia — have been widely adopted. The jury remains out for other SSI-prevention issues, including the best preparations for preoperative skin antisepsis and the benefits of decolonizing Staphylococcus aureus nasal carriers. Two randomized, controlled, multicenter trials (both partially supported by industry) now shed light on these prevention approaches.
Investigators in the U.S. randomized 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I) and assessed the occurrence of SSIs within 30 days postoperatively. In an intent-to-treat analysis, CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I; P=0.004) and lower rates of superficial (4.2% vs. 8.6%; P=0.008) and deep (1.0% vs. 3.0%; P=0.05) incisional SSIs. No significant between-group differences were seen in rates of organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%).
Researchers in the Netherlands, using real-time PCR, screened 6771 newly admitted patients for S. aureus nasal carriage. Of the 1251 S. aureus carriers, 918 were randomized to receive 5 days of treatment with 2% mupirocin nasal ointment (twice daily) plus CHG soap (daily) or with placebo. The rate of healthcare-associated S. aureus infections was significantly lower in the mupirocin-CHG group than in the placebo group (3.4% vs. 7.7%; relative risk, 0.42; 95% confidence interval, 0.23–0.75). Most enrolled patients were surgical (88.1%), and most S. aureus infections were SSIs (81.6%). Among surgical patients, the rate of deep SSIs was lower in the mupirocin-CHG group (0.9% vs. 4.4%; RR, 0.21; 95% CI, 0.07–0.62).
Darouiche RO et al. Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis. N Engl J Med 2010 Jan 7; 362:18.
Bode LGM et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010 Jan 7; 362:9.
Wenzel RP. Minimizing surgical-site infections. N Engl J Med 2010 Jan 7; 362:75.
Comment
CHG-alcohol, which is already preferred for skin preparation before intravascular catheter placement, should now replace P-I for preoperative skin antisepsis. The implications of the S. aureus decolonization study are less clear because the relative importance of the two topical therapies (nasal mupirocin and CHG soap) is unclear. Until we know whether screening and targeted decolonization is superior to preoperative bathing of all patients with CHG soap, this approach should be reserved for high-risk procedures (e.g., cardiac surgery, orthopedic implants). As an editorialist points out, interventions that can be applied to all patients and that target all organisms are preferred to organism-specific approaches that carry the added expense and logistical difficulty associated with identifying carriers before surgery.