Preadmission Showers Could Reduce Surgical Site Infections

Marcia Frellick

August 27, 2015

Although there is widespread agreement that showering with chlorhexidine gluconate reduces skin bacteria before surgery, there are no definitive data that this practice is effective in reducing postoperative surgical site infections (SSIs). New data, published online August 26 in JAMA Surgery, may settle that question.

Charles E. Edmiston Jr, PhD, from the Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin in Milwaukee, and colleagues suspected the apparent lack of clinical benefit was because previous studies were inconsistent in how the protocol was performed.

They analyzed seven studies and found many differences in the methodologies. Some patients showered once, and others showered two or three times. There was no evidence that patient adherence was measured. In five of the seven studies, investigators failed to include a 30-day surveillance period after surgery.

Therefore, the authors designed their own study to determine how many showers patients should take with chlorhexidine gluconate and how long they should pause before rinsing off to achieve the maximum persistent skin antisepsis.

They enrolled 120 healthy volunteers and randomly assigned them to two chlorhexidine gluconate 4% showering groups. One group of 60 showered twice, and another group of 60 showered three times. Both groups included three subgroups (no pause before rinsing, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each.

The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in patients who paused for 1 and 2 minutes before rinsing compared with the no-pause group in participants who took two or three showers.

However, concentrations of chlorhexidine gluconate did not differ significantly between two and three showers or between the 1- and 2-minute pauses.

According to their research, the preoperative regimen should be as follows, the authors say:

  1. All patients should take at least two preadmission showers with chlorhexidine gluconate 4% the night before and the morning before surgery.

  2. Patients should pause for 1 minute before rinsing.

  3. Patients should use a total volume of 118 mL chlorhexidine gluconate 4% during each shower.

  4. Use a text, email, or voicemail alert to remind the patient to complete the protocol.

The authors say the costs for two bottles of solution and establishing alerts would be less than $9 per patient.

The study does not make a direct connection to use of this protocol and reduction in SSIs. However, the standardized approach "provides a cognizant pathway for achieving high, sustainable concentrations of chlorhexidine gluconate on the skin that are sufficient to inhibit or kill microbial pathogens harbored on the skin at the surgical site," the authors write.

In an invited commentary, Zeinab M. Alawadi, MD, and Lillian S. Kao, MD, from the Department of Surgery, University of Texas, Houston, say having a standard approach to showering with chlorhexidine gluconate may not be a complete answer, but it may be more feasible than other more intensive regimens.

"Is there any less evidence for chlorhexidine gluconate, 4%, washes than for other interventions that have been used in SSI bundles, such as a separate tray for closure of fascia and skin or restriction of traffic in the operating room?" they ask.

They note that a promising, safe, low-cost intervention should be seriously considered, but ease of implementation and patient adherence are also important in interventions, and those elements have not been well studied with chlorhexidine gluconate.

Despite those limitations, they conclude, "If we limit interventions to those with definitive, high-quality evidence, then our efforts to reduce SSIs will certainly be a wash."

The study was supported in part by Clorox Healthcare. Two coauthors received grant support from Clorox Healthcare. The other authors of the study and the authors of invited commentary have disclosed no relevant financial relationships.

JAMA Surg. Published online August 26, 2015. Article full text, Commentary extract

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