Evidence Based Practice

Regarding Chlorhexidine
Use to Prevent Surgical
Presented by:
Site Infection
Cindy Magirl
Eric Nelson
Tennille Sassano
Jennifer Vicarie

What does the literature say about the

use of Chlorhexidine in the prevention
of surgical site infections (SSIs)?

 It is estimated that between 750,000 and 1

million SSIs occur in the United States each
year (Edmiston et al., 2010).
SSIs remains a substantial cause of postoperative morbidity and increased health
care costs (Riley et al., 2012).
SSIs result in 3.7 million additional hospital
days and $845 million spent nationally.
(Zinn et al., 2010)

The aim is to
evaluate the
effectiveness
of evidencebased
prevention
and control
strategies to
reduce rates
of SSIs.

TABLE 1. Selected Patient and Procedural

Characteristics Associated With Increased
Risk of Surgical Site Infections

Patient (intrinsic)

Procedural (extrinsic)

Age
Diabetes (metabolic disease)
Perioperative hyperglycemia
Tobacco use
Concurrent infection (distant)
Obesity
Malnutrition
Immunocompromise
Low preoperative serum albumin
level
Corticosteroid use
Prolonged hospitalization before
surgery
Prior radiation to surgical field tissue
Staphylococcus aureus colonization

Lack of preoperative shower

Site shaving the night before
surgery
Extended operative time
Flawed skin antisepsis
Flawed surgical prophylaxis
Effects of the OR environment
(eg, hypothermia)
Break in aseptic technique
Hypothermia or hypoxia
Perioperative blood transfusion
Surgical technique
Hemostasis
Tissue trauma

Edmiston et al., 2010

Surgical Studies
1978 study showed that application of
CHG to the skin surface resulted in a
greater microbial log reduction and it
persisted several hours after application
compared with povidone iodine
1988 documentation shows that repeat
application of CHG 4% was superior to a
single shower in reducing staphylococcal
skin contamination
Edmiston et al., 2010

Total Joint Replacement

Surgical Study
POSTPRE-INTERVENTION
GROUP
727 patients
Self bathing of
povidone iodine
night prior to
surgery
After 3 months,
3.19% infection
rate

INTERVENTION
GROUP
737 patients
Self bathing of CHG
2% impregnated
polyester cloths night
prior to surgery and
staff assisted bath on
admission to hospital
After 3 months, 1.59%
infection rate

Edmiston et al., 2010

Appraisal
Overall the evidence is strong in supporting the use
of CHG. In the journal article, the authors identify
some weakness within the studies they included.
For example, in one of the studies the author lists
several problematic issues involving study design,
implementation, and analysis. Another weakness of
this literature review is several studies were
included and because of this, there was a lot of
pertinent information left out in order to summarize
the amount of information.

LOW TRANSVERSE CESAREAN SECTION

SURGICAL STUDY
Observational study conducted to determine LTCS
SSI rates and impact of infection control
interventions from Oct. 2005-Dec. 2008
Included use of 2% Chlorhexidine gluconate (CHG)
for surgical skin prep and no rinse CHG cloths
Four study periods

Riley et. al, 2012

Low Transverse Cesarean

Section (LTCS) Surgical Study
Time Line
Baseline Period
(October, 2005 - March, 2006)
SSI rate retrospective identification for comparison

Riley et al., 2012

Low Transverse Cesarean Section

(LTCS) Surgical Study Time Line
Outbreak Period
(April, 2006 October, 2006)
Obstetrics and gynecology (OBGYN) clinicians noticed an
increase in post-LTCS patients returning with SSI in 2006
Focused on identifying critical control points and analyzing
hazards by directly observing LTCS procedures
Labor and delivery (L&D) operating room (OR) walks
Self administered employee survey

Limited personnel traffic during surgery

Improved surgical hand scrub
Modified surgical skin preparation
Changed the timing of antimicrobial prophylaxis
Revised L&D OR policies
Performed SSI prevention in-services
Completed employee competency training

Low Transverse Cesarean Section

(LTCS) Surgical Study Time Line
Intervention One Period
(November, 2006 September, 2007)
Focused on changing practice and fully
implementing all recommendations from outbreak
period
Fully implemented recommendations based on
the CDCs SSI prevention guidelines

Low Transverse Cesarean Section

(LTCS) Surgical Study Time Line
Intervention Two Period
(October, 2007 - December, 2008)
Chloroprep, a combination of 2% CHG and 70% isopropyl
alcohol (IPA) replaced povidone-iodine for surgical skin
prep
Implementation of preoperative CHG skin cleansing
program
Scheduled patient performed night before surgery
Unscheduled nurse performed as part of pre-surgery prep

Moved into new hospital building

Changed administration time of antibiotic
Nurses in OBGYN clinics educated patients about SSI
prevention

Appraisal
Evidence in itself was strong based on the
reduction of SSIs during the study. However,
there were also several limitations to the study:
Implementation of multiple interventions at
the same time. Which intervention was
successful?
Cost analysis was not studied in depth.
Although patients were instructed to contact
their physician for signs and symptoms of
infection, no official follow-up was
coordinated.

Intra-operative Patient Skin Prep

Agents: Is There a Difference?
The authors conducted an article review to
evaluate if there is a superior intra-operative prep
available for open abdominal and general surgery
procedures.
The authors concluded that there is no one prep
that is superior in all situations.

Zinn et al., 2010

Comparison of Prep Solutions

Povidone-iodine
Advantages
Excellent grampositive activity
Good gram-negative
activity
Broad spectrum
Moderate rapidly of
action
Long established as
an effective agent

Chlorhexidine
Advantages
Excellent grampositive activity
Good gram-negative
activity
Broad spectrum
Moderate rapidly of
action
Excellent persistent
and residual activity

Zinn et al., 2010

Comparison of Prep Solutions

Povidone- iodine
Disadvantages
Minimal persistence
and residual activity
Decreased
effectiveness in the
presence of blood and
organic material
Lack of recent
empirical evidence

Chlorhexidine
Disadvantages
Contraindicated for
use on eyes, ears,
brain and spinal tissue,
genitalia, mucus
membranes
Inactivity in the
presence of saline
solution
Drying effect on the
skin

Zinn et al., 2010

Appraisal
Only 29 studies were involved in this literature
review
Each prep agent has specific advantages and
disadvantages.
The study reviewed several prep agents
because of the considerations for patient
allergies, natural flora, surgical site, and
surgeon preference.
The study did not include any research of
ChloraPrep
The researchers stated that they did not find
adequate information to prove one prep agent
used exclusively.
The article was easy to read however lacked

Decreasing methicillin-resistant
staphylococcus aureus surgical site
infections with chlorhexidine and
mupirocin.
This was a case controlled study of 29,862
patients over a 3 year period
Only orthopedic, cardiac, neurological, and
vascular cases were in the study

Thompson & Houston, 2012

Purpose of the study

To determine if a regimen of 2% chlorhexidine for
5 days pre-op along with intra-nasal mupiricin
decreases MRSA surgical site infections

Thompson & Houston, 2012

Results

Cardiac 92% decrease

Orthopedic 43% decrease
Neurology 100% decrease
Vascular 52% decrease

Total MRSA SSI reductions from 2006-2008

Thompson & Houston, 2012

Appraisal
Pre-operative bathing with 2% chlorhexidine and
use of mupiricin ointment may be beneficial in
reducing MRSA SSIs

Our experience with CHG

We currently use a variety of products

ChloraPrep w/ tint
4% chlorhexidine solution
ChloraPrep SEPP
2% chlorhexidine cloths

Recommendations
Use of chlorhexidine intra-op skin prep when not
contraindicated
Appropriate education to patients and staff about
use and application
Pre-operative chlorhexidine bathing
Ongoing follow up on post operative infection rate

References
Edminster, C.E. Jr, Okoli, O., Graham, M.B., Sinski, S., & Seabrook,
G.(2010). Evidence for using chlorhexidine gluconate preoperative
cleansing to reduce risk of surgical site infection. Association of
Perioperative Registered Nurses Journal, 92(5), 509-518.
Riley, M., Suda, D., Tabsh, K., Flood, A., & Pegues, D.(2011).
Reduction of surgical site infections in low transverse cesarean
section at a university hospital. American Journal of Infection
Control, doi:10.1016/j.ajic.2011.12.011
Thompson, P., Houston, S. (2012). Decreasing methicillin-resistant
staphylococcus aureus surgical site infections with chlorhexidine
and mupirocin. American journal of infection control, 9(3).
Zinn, J., Jenkins, J., Swofford, V., Harrelson, B., & McCarter, S.(2010).
Intraoperative patient skin prep agents: Is there a difference?
Association of Perioperative Registered Nurses Journal, 92(6), 662671. doi:10.1016/j.aorn.2010.07.016

References (Photographs)
CMPA Good Practices Guide. 2012. [Surgical
Preparation]. Retrieved from http://www.cmpaacpm.ca
Mayo Healthcare Pty. Ltd. n.d. Interventional
Hygiene. Retrieved from http://
www.mayohealthcare.com.au/products/Resp_intvH
ygiene_skinPrep.htm