Efficacy of skin preparation solutions in patients with total knee replacement: A randomized controlled trial

Purpose Surgical site infection following total knee replacement is considered as one of the most severe postoperative complications. The presence of bacteria at the surgical site is the most important risk factor and therefore it is essential to prevent infection through appropriate preoperative skin preparation. The purpose of this study was to examine the presence and type of native bacteria on the incision site and to assess which skin preparation is most effective to sterilize those native bacteria. Methods Scrub-and-paint 2 step method was used for standard preoperative skin preparation. 150 patients who underwent total knee replacement were grouped into 3 groups- Group 1 (povidone-iodine scrub-and-paint), Group 2 (chlorhexidine gluconate paint after povidone-iodine scrub), and Group 3 (povidone-iodine paint after chlorhexidine gluconate scrub). 150 specimens of post-preparation swabs were obtained and cultured. To analyze the native bacteria at the total knee replacement incision site, 88 additional swaps were performed before skin preparation and cultured. Results The positive rate of bacterial culture after skin preparation was 5.3% (8/150). Positive rates of the groups were 12% (6/50) in group 1, 2% (1/50) in group, 2 and 2% (1/50) in group 3 and positive rates of bacterial culture after skin preparation in group 2 and group 3 were lower than in group 1 (p = 0.037). Among the 55 patients who had positive bacterial culture prior to skin preparation, 26.7% (4/15) in group 1, 5.6% (1/18) in group 2, and 4.5% (1/22) in group 3 were positive. Group 1 showed 7.64 times higher positive bacterial culture rate after skin preparation than group 3 (p = 0.084) Conclusion During skin preparation prior to total knee replacement surgery, chlorhexidine gluconate paint after povidone-iodine scrub or povidone-iodine paint after chlorhexidine gluconate scrub had a superior effect on sterilizing native bacteria compared to povidone-iodine scrub-and-paint method.

[1]  Bin Guo,et al.  Preoperative Antisepsis with Chlorhexidine Versus Povidone-Iodine for the Prevention of Surgical Site Infection: a Systematic Review and Meta-analysis , 2020, World Journal of Surgery.

[2]  M. Whitehouse,et al.  Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis , 2016, PloS one.

[3]  K. Kaye,et al.  Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis , 2015, Infection Control & Hospital Epidemiology.

[4]  S. Awad,et al.  Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. , 2015, JAMA surgery.

[5]  B. Medhi,et al.  Comparison of the efficacy of chlorhexidine gluconate versus povidone iodine as preoperative skin preparation for the prevention of surgical site infections in clean-contaminated upper abdominal surgeries , 2015, Surgery Today.

[6]  Ana Luzia Rodrigues,et al.  Incidence of surgical site infection with pre-operative skin preparation using 10% polyvidone-iodine and 0.5% chlorhexidine-alcohol. , 2013, Revista do Colegio Brasileiro de Cirurgioes.

[7]  Heather N. Watson,et al.  Economic burden of periprosthetic joint infection in the United States. , 2012, The Journal of arthroplasty.

[8]  C. Edmiston,et al.  Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. , 2010, AORN journal.

[9]  C. Wiedermann,et al.  Bacillus species infective arthritis after knee arthroscopy. , 2010, Surgical infections.

[10]  A. Johnson,et al.  Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. , 2010, The Journal of arthroplasty.

[11]  Michael C. Mosier,et al.  Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. , 2010, The New England journal of medicine.

[12]  T. Wright.  Efficacy of Surgical Preparation Solutions in Shoulder Surgery , 2010 .

[13]  Manfred S. Green,et al.  Seasonality of Bacillus species isolated from blood cultures and its potential implications. , 2009, American journal of infection control.

[14]  A. Apisarnthanarak,et al.  Comparison of surgical wound infection after preoperative skin preparation with 4% chlorhexidine [correction of chlohexidine] and povidone iodine: a prospective randomized trial. , 2009, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[15]  G. de Lissovoy,et al.  Surgical site infection: incidence and impact on hospital utilization and treatment costs. , 2009, American journal of infection control.

[16]  T. Perl,et al.  Chlorhexidine: expanding the armamentarium for infection control and prevention. , 2008, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[17]  Mary Beth Digison.  A Review of Anti‐septic Agents for Pre‐operative Skin Preparation , 2007, Plastic surgical nursing : official journal of the American Society of Plastic and Reconstructive Surgical Nurses.

[18]  C. Zouboulis,et al.  Sexual hormones in human skin. , 2007, Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme.

[19]  Rajul A. Patel,et al.  Evaluation of gender difference in skin type and pH. , 2006, Journal of dermatological science.

[20]  David D. Smith,et al.  Paint-only is equivalent to scrub-and-paint in preoperative preparation of abdominal surgery sites. , 2005, Journal of the American College of Surgeons.

[21]  D. Patel,et al.  Chlorhexidine Provides Superior Skin Decontamination in Foot and Ankle Surgery: A Prospective Randomized Study , 2005, Clinical orthopaedics and related research.

[22]  M. Botte,et al.  Efficacy of surgical preparation solutions in foot and ankle surgery. , 2005, The Journal of bone and joint surgery. American volume.

[23]  R. Marples.  Sex, constancy, and skin bacteria , 2004, Archives of Dermatological Research.

[24]  Kurtis R Hort,et al.  Residual Bacterial Contamination After Surgical Preparation of the Foot or Ankle With or Without Alcohol , 2002, Foot & ankle international.

[25]  J. Pyrek,et al.  Evaluation of a waterless, scrubless chlorhexidine gluconate/ethanol surgical scrub for antimicrobial efficacy. , 2001, American journal of infection control.

[26]  P. Astagneau,et al.  Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance. , 2001, The Journal of hospital infection.

[27]  Teresa C. Horan,et al.  Guideline for Prevention of Surgical Site Infection, 1999 , 1999, Infection Control & Hospital Epidemiology.

[28]  T. Horan,et al.  Guideline for prevention of surgical site infection. , 2000, Bulletin of the American College of Surgeons.

[29]  B. Hazleman,et al.  Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. , 1997, British Journal of Rheumatology.

[30]  K. Reimer,et al.  Povidone-iodine in antisepsis--state of the art. , 1997, Dermatology.

[31]  C. Nelson,et al.  Comparison of a one-step iodophor skin preparation versus traditional preparation in total joint surgery. , 1990, Clinical orthopaedics and related research.