Preoperative Skin Cleansing With Chlorhexidine Gluconate

Jane C. Rothrock, DNSc, MSN, BSN, CNOR, FAAN

Posted: 03/11/2010

How effective is the 2% CHG solution for preop bathing? Are 2 baths with 4 % CHG
sufficient for skin antisepsis?

Response from Jane C. Rothrock, DNSc, MSN, BSN, CNOR, FAAN

Professor and Director, Perioperative Programs, Delaware County
Community College, Media, Pennsylvania

An estimated 500,000 surgical site infections (SSIs) occur each year. Patients with a
SSI have a 2-11 times greater risk for death than surgical patients without a SSI, and
spend approximately 7-10 more days in the hospital at additional costs of $3000 to
$29,000.[1] The use of an antimicrobial skin agent such as chlorhexidine gluconate
(CHG) with a bath or shower works in 2 ways to prevent SSI. The simple act of
mechanical friction and rinsing removes transient skin microbes. The addition of an
agent such as CHG provides persistent activity, which further reduces the level of the
patient’s own skin flora. For patients scheduled for a surgical procedure, the
recommendation from the Association of periOperative Nurses is to use 4% CHG for
bathing or showering the night before and the morning of the scheduled procedure.
[2]
The details of that recommendation have been previously reviewed in an article
about preoperative showers and baths. [3] It is probably safe to say that using
aqueous 4 % CHG for 2 baths or showers is an adequate way to begin skin antisepsis
in patients scheduled for surgery. This practice has been studied in relation to
vascular catheter-related infection and shown to be effective. [4] Although the
discussion about the addition of alcohol to the product used for cleaning the
vascular catheter insertion site is ongoing, (because alcohol is an effective and rapid-
acting skin antiseptic), the 2% aqueous solution is less irritating for patients to use
in a shower or bath.

As noted above, controversy exists about the use of 2% CHG-based preparations for
cleansing vascular catheter insertion sites. In their 2002 Guidelines for the
Prevention of Intravascular Catheter-Related Infections, O'Grady and associates note
that a 4 % chlorhexidine-based preparation is preferred. [5] This recommendation
was based on the 1991 study by Maki and colleagues that demonstrated that 2%
aqueous CHG was more effective than aqueous povidone-iodine in reducing
catheter-related infections.[4] During the public comment period for the 2009
updated draft guidelines for the Prevention of Intravascular Catheter-Related
Infections a suggestion that practitioners "...use a greater than 0.5% alcoholic
chlorhexidine gluconate-based preparation for skin antisepsis" was made. [6] Two
new studies support this suggestion.

Because the patient's skin is a major source of pathogens, preoperative skin

cleansing has been of great interest in the prevention of SSIs. Which skin antiseptic
to use remains a topic of research. A recent prospective randomized trial involving 6
hospitals posed the hypothesis that preoperative skin cleansing with CHG and
alcohol would be more protective against infection than povidone-iodine. [7] Patients
scheduled for clean-contaminated surgery were randomly assigned to preoperative
antisepsis with 4 % CHG-alcohol (n = 409) or povidone-iodine (n = 440). Data
analysis confirmed that patients in the CHG-alcohol group had a significantly lower
overall SSI rate than those in the povidone-iodine group -- 9.5% vs 16.1%. The 2%
CHG-alcohol was significantly more protective than povidone-iodine against both
superficial-incisional (4.2% vs 8.6%) and deep incisional (1% vs 3%) infections, but
not against organ-space infections (4.4% vs 4.5%). The researchers concluded that
preoperative skin cleansing with CHG-alcohol is superior to povidone-iodine for
preventing surgical-site infection after clean-contaminated surgery.

In a study with a different approach, a randomized, double-blind, controlled,

multicenter trial was conducted to determine whether rapid identification of
Staphylococcus aureus nasal carriers at the time of admission, followed by treatment
with mupirocin nasal ointment twice a day for 5 days and daily baths with CHG soap
would reduce the risk of hospital-associated S aureus infections.[8] The study was
prompted by the knowledge that nasal carriers of high numbers of S aureus bacteria
have a 3-6 times higher risk for healthcare-associated infections with this organism.
Intranasal application of mupirocin has previously been shown to be effective for
decolonization of S aureus and prevention of invasive infections.

Study results demonstrated a rate of S aureus infection of 3.4% (17 of 504 patients)
in the mupirocin-CHG group compared with 7.7% (32 of 413 patients) in the
placebo group. The effect of mupirocin-CHG treatment was most pronounced for
deep SSIs -- 0.9% for the mupirocin-CHG group vs 4.4% for the placebo group. Thus,
these researchers from The Netherlands drew the conclusion that rapid nasal
screening for S aureus followed by decolonization of the nose and skin with
mupirocin ointment and CHG soap significantly reduced hospital-acquired S aureus
infections. In an accompanying editorial, infection control expert Richard Wenzel,
MD, suggested that the screening protocol could be reserved for patients having
cardiac surgery, receiving implants, or who are immunocompromised. [10]

To conclude, your question is a very thoughtful one. I believe it is safe to say that the
use of aqueous 4% CHG for the 2 recommended preoperative baths or showers is
indeed adequate to begin the process of surgical skin antisepsis.
Bu saya kirim kembali, kemarin tdk sampai

Dudung Sidik | Professional Service

Skin & Wound Care Division
3M Indonesia, Perkantoran Hijau Arkadia Menara F Lt.8 Jl TB Simatupang kav. 80 |
Jakarta 12520,Indonesia
Office: +622129974000 | Mobile: +6285882444158 | Fax: +622178832172
dsidik@mmm.com | www.3M.com

----- Forwarded by Dudung Sidik/IA-Indonesia/3M/US on 01/17/2012

07:12 AM -----

From: Dudung Sidik/IA-Indonesia/3M/US

To: costypandjaitan@yahoo.com, wardanelayunus@yahoo.com,
tutiduadelapa@yahoo.co.id, sarisastrawinata@yahoo.com,
tutyduadelapan@yahoo.co.id
Cc: Almazia Pratita/IA-Indonesia/3M/US@3M-Corporate, Amalia Ayu
Wulandari/IA-Indonesia/3M/US@3M-CORPORATE, Linda
Fitriana/IA-Indonesia/3M/US@3M-CORPORATE
Date: 01/16/2012 03:56 PM
Subjec INS Sholarship NOW OPEN
t:

Dear ibu-ibu

FYI,
INS is now accepting applications for Ireta scholarship, which is intended to support
international nurses to participate their annual meeting in Las Vegas.

Two scholarships will be awarded with US $5000 each.

In 2011, Sai Bala Madathil from India received the prestigious award and recognized
during the INS annual meeting in Kentucky.

Application Requirement:
 One-page summary to demonstrate how attending an INS National Meeting
will benefit their patients, community, and practice by contributing to the
base of infusion knowledge in their country.
  The applicant must also demonstrate how the knowledge gained at an INS
meeting might be incorporated into existing modes of infusion care abroad.
 Application must be submitted in English.
 Fill up the attached form (page 6).
Ask the customer to send directly the (1) application form and (2) one-
page summary to Christopher Hunt, Executive Vice President of INS through his
email Chris.Hunt@ins1.org

Application timeline:
January 11 Call for Application begins
February 10 Application process closes
March Review and selection completed

Jadi:

yang perlu ibu-ibu lakukan adalah:

1. Membuat 1 halaman kesimpulan ttg pentingnya kita ikut seminar di INS Meeting
lihat point 1 diatas.
2. Mengisi identitas yang terdapat di Hal 6 PDF diatas, caranya print dahulu materi
PDF nya kemudian isi, scan dan dikrim bersama one-page summary nmr satu diatas,
ke alamat email diatas.

Please forward this email to your other colleagues, thanks

Regards

Dudung Sidik | Professional Service

Skin & Wound Care Division
3M Indonesia, Perkantoran Hijau Arkadia Menara F Lt.8 Jl TB Simatupang kav. 80 |
Jakarta 12520,Indonesia
Office: +622129974000 | Mobile: +6285882444158 | Fax: +622178832172
dsidik@mmm.com | www.3M.com