The proposed 2015 changes to AORN and CDC recommendations for pre-operative patient skin antisepsis and surgical site infection prevention no longer advise patients to shower or bathe with chlorhexidine gluconate (CHG) or an antiseptic agent twice prior to surgery despite clinical data that supports multiple CHG skin applications as part of a strategy to reduce SSI risk. These proposed recommendation changes could cause confusion by leaving pre-operative cleansing recommendations open to interpretation. We asked Charles Edmiston Jr., PhD, CIC, hospital epidemiologist for the Medical College of Wisconsin in Milwaukee and director of its Surgical Microbiology Research Laboratory, what these updates mean to your surgical site infection reduction efforts.
Q: Do AORN's updated guidelines (tinyurl.com/nwoohug) and the CDC's long-awaited, soon-to-be-published revision of its 1999 SSI prevention advice differ from what's been recommended before?
A: The CDC and AORN are in lock-step in what they recommend, with both saying patients should shower at least 1 time on the night before or the day of surgery with soap or an antiseptic agent. What's getting the most attention in the infection prevention community is that they're not recommending one over another. The soap may or may not be antimicrobial. And this is saying, however indirectly, that they find no evidence that chlorhexidine gluconate, for example, provides any more protection against post-op surgical site infections than other cleansing options.
Q: You've conducted numerous studies on the use of CHG as a skin prepping agent. How should infection preventionists reconcile the previous evidence that's been pointing to CHG with these updates that de-emphasize the importance of an antiseptic approach to pre-op bathing?
A: The focus for the CDC's recommendation is somewhat narrow. According to the proposed guideline we read, it's based only on the available randomized controlled trials that were published before a cutoff date in 2011. Now, CHG's been around for a long time. If you look at the wealth of data out there, it has a tremendous capacity for microbial kill. The drug is very, very effective. I'm a big believer in evidence, and there's no doubt in my mind that the use of an antiseptic agent, from a scientific and a pragmatic perspective, is an effective intervention in reducing microbial flora. My role is to continue looking at the science and developing interventions for patients and procedures, and my colleagues and I are publishing a rebuttal to the updated guidelines in a clinical journal this spring.
Q: Are there other recommendations we should be looking to for direction on pre-op patient skin antisepsis?
A: There's a growing body of research that views antiseptic skin preparation as a key component of "surgical care bundles" to prevent SSIs. Combining evidence-based individual interventions will reduce risk, the research suggests. For example, while the antiseptic shower reduces microbial flora on the skin, additional evidence-based interventions such as nasal swabbing for MRSA and Staph aureus surveillance, pre-op antibiotics and antimicrobial closures limit other infection risks. A 2014 study by University of Michigan researchers (tinyurl.com/kboajyh) found that applying a surgical bundle of 6 interventions to colorectal surgery patients reduced the post-op infection rate from 18% to 2%. The subtraction of 1 or more interventions from the regimen, though, showed a decline in the results. What we're trying to figure out now is, what plays the primary role in reduction, and which interventions provide an optimal fit to which patient populations?
Q: AORN's guidelines also cover the issues of surgical site hair removal and the selection and application of skin prep solutions. Should those practices be addressed in surgical bundles?
A: While the clipping of hair is partly a dogmatic practice (some surgeons still order it every time) and partly a pragmatic practice (hair saturated with alcohol-based prep can create a risk of fire) it's not as urgent an intervention as the application of an antiseptic agent, whether CHG or povidone-iodine both of which have uses on the anatomy and should be on hand.
Q: Unlike other antimicrobial interventions, the practice of pre-op showering is entirely in patients' hands. How can we ensure uniform results?
A: Timely reminders are especially effective. Elective procedures like orthopedic surgeries are scheduled 10 to 14 days out, so it's not only important to instruct patients in a standardized protocol how to shower, how often to shower, how long to shower, what to use, how much to use but also to remind them to take these steps. Voicemails, e-mails, even text messages will significantly increase patient compliance, as we reported in a study (tinyurl.com/njpwvmz) in the Journal of the American College of Surgeons last year.
People may see pre-op showers as a mundane exercise, but I view them as a therapeutic practice, like antibiotics' ability to deliver a dose sufficient to inhibit or kill bacteria. We have data showing a pharmacokinetic approach for using CHG and demonstrating how it can attain maximum effect. The things we do before surgery can provide a great benefit in defending the vulnerability of the surgical wound afterward. In 1920, the British abdominal surgeon Lord Moynihan said, "Every operation is an experiment in bacteriology." Imagine your surgeons saying that before a case today. We have much better data now.