Advances in Preventing Surgical-Site Infections

Summary and Comment |
January 6, 2010

Advances in Preventing Surgical-Site Infections

  1. Daniel J. Diekema, MD, MS

Preoperative cleansing with chlorhexidine-alcohol (rather than povidone-iodine), and detecting and decolonizing Staphylococcus aureus nasal carriers, were each found to reduce the infection rate.

  1. Daniel J. Diekema, MD, MS

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).


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.


Reader Comments (2)

Bernard L. Rosenfeld, M.D.

Most surgeons I have discussed this article with changed their practice for preoperative skin antisepsis. I did the next morning. Unfortunately, few know about this study. I checked on the hospital cost of 4 ounces of povidone-iodine, it is $0.73 and chlorhexidine and alcohol is $5.37. This difference will cause some resistance to change. Large Houston hospitals like MD Anderson have completely changed to chlorhexidine while many small hospitals did not have it available for surgical skin antisepsis. We can't expect hospitals to stock CHG-alcohol unless surgeons or Infectious Disease departments request it. Your feedback would be very important to me. All hospital's surgeons and infectious disease departments are interested in any intervention that would decrease surgical site infections. This information should be a CDC -1A or 1B recommendation to prevent surgical site infections. How can we get this information out to infectious disease departments and surgeons?

Competing interests: None declared

Marysia Meylan

I thought supplemental O2 and control of blood sugar were also an important part of prevention.

Competing interests: None declared

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Daniel J. Diekema, MD, D(ABMM)

Contributing Editor 2010 – 2014, Associate Editor 2006-2009