Effect of pre-operative skin preparation on post-operative wound infection.
RG Shirahatti, RM Joshi, YK Vishwanath, N Shinkre, S Rao, JS Sankpal, NK Govindrajulu
Dept of Gastroenterology Surgical Services, TN Medical College, Bombay, Maharashtra.
R G Shirahatti
Dept of Gastroenterology Surgical Services, TN Medical College, Bombay, Maharashtra.
A prospective randomised trial was carried out to compare the efficacy of method of scrubbing the operative site for ten minutes with an antiseptic (GpA; n = 68) with a simplified method where the antiseptic was merely painted onto the operation site (GpB; n = 67). The median age, sex distribution and the types of procedures done in each group were similar as was the antibiotic policy. There were a total of 11 patients who got infected, 6 in the group A and 5 in the group B. No significant difference could be demonstrated in the infection rates between the two groups. It is concluded that the old method of prolonged scrubbing the operation site can safely be omitted to a more simplified version.
|How to cite this article:|
Shirahatti R G, Joshi R M, Vishwanath Y K, Shinkre N, Rao S, Sankpal J S, Govindrajulu N K. Effect of pre-operative skin preparation on post-operative wound infection. J Postgrad Med 1993;39:134-6
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Shirahatti R G, Joshi R M, Vishwanath Y K, Shinkre N, Rao S, Sankpal J S, Govindrajulu N K. Effect of pre-operative skin preparation on post-operative wound infection. J Postgrad Med [serial online] 1993 [cited 2020 Jan 29 ];39:134-6
Available from: http://www.jpgmonline.com/text.asp?1993/39/3/134/615
The current concepts of preparation of the patient's skin and surgeons' hands are based on the pioneering work done by Lister and others in the middle of the last century. However, in 1961, Lowbury stated "Although skin disinfection has been the subject of interest and research over hundred years, there is no generally accepted procedure for use either at the operation site or in the hands of surgeons and nurses. Moreover, many discrepancies in the evaluation of individual antiseptics have been due to the differences and deficiencies in the techniques of testing." Thirty years later, there is little in the literature to suggest that traditional practices of unproven or even doubtful value have been abandoned. In the majority of Indian hospitals, the traditional method of pre-operative skin preparation is still practiced. This generally consists of scrubbing the part vigorously for seven to ten minutes with a solution containing an antiseptic detergent, the excess detergent being removed by a dry swab. This is followed by the application of an alcohol based antiseptic. It is known however that vigorous scrubbing of the skin can release large numbers of organisms, which reside in the deeper layers of the skin. It is quite possible to achieve satisfactory reductions in the number of skin organisms by merely painting an antiseptic on to the operation site and allowing it to act for a short time. We decided therefore to conduct a prospective randomised version where the antiseptic was merely painted on to the operation site without scrubbing it.
All patients undergoing elective and emergency operations in a single surgical unit during a six month period between 1st Jan ‘91 and 31st May ‘91 have been included in this study. Anorectal operations, abscesses and day care procedures were excluded from the study. All the patients for elective surgery were admitted a day prior to surgery. Hair removal was done on the night before surgery by shaving. Patients had a bath with nonmedicated soap and water on the morning of the operation and were issued freshly laundered clothes. They were then randomised into two groups; group A wherein skin preparation done by traditional method, i.e.; scrubbing the site for full ten minutes with a solution containing 0.75% chlorhexidine and 1.5% cetrimide followed by wiping the area dry and application of 1% iodine in 70% spirit, and group B in which the site was prepared by painting the same antiseptics which were allowed to remain for about two to three minutes before being wiped off. This was followed by the application of 1% iodine in 70% spirit. The antibiotic policy in both groups was identical i.e. no antibiotics in clean cases, three dose peri-operative antibiotics for clean contaminated cases and antibiotics for three to five days in frankly contaminated and dirty cases. All patients who underwent a clean procedure and did not need intravenous fluids and those not having a drain were discharged the next day to be followed up in the out-patient department for cheek dressings. Those patients needing hospitalization had to check dressing done on the third day. All wounds were checked for any evidence of infection and discharge, which was cultured. Wound infection was defined as wound showing redness or swelling of surrounding area or had a discharge irrespective of whether any organisms were grown in the discharge. Specific antibiotic therapy was instituted in patients who showed evidence of infection.
Data analysis was done by Student's T-test for comparing mean age in different groups. Mantel-Haenzel Chi square test was used to compare the proportion of patients getting infected in the two groups.
A total of 135 patients were included in the study (103 males and 32 females). Sixty-eight patients were randomised to group A (scrub group) and 67 to group B (paint group). The mean age and sex distribution of patients was not significantly different between the two groups and when compared to the total.
Ninety-one of 135 patients had a clean procedure, 22 underwent clean contaminated procedures and in 22, the procedures were for frankly contaminated conditions. The proportion of the type of procedures was not significantly different between the two groups [Table:1].
There were a total of 11 patients who showed evidence of post- operative wound infection (8%). Of these, 6 belonged to group A (8.82%) and 5 to group B (7.42%). The overall infection rate in the two groups when compared was not significantly different. Of 6 patients in group A getting infected, 2 had clean procedures, 3 clean contaminated, and 1 frankly contaminated procedure. Of 5 incidences of infections in group B, 2 followed clean procedures, 1 a clean contaminated procedure and 2 others followed frankly contaminated procedures [Table:2]. Therefore, the proportion of different procedures getting infected in the two groups was not significantly different (Mantel-Haenzel Chi-square = 221; cif = 2; p=0.9998; odds ratio = 1.229; 95% confidence limits: 1.948E-12 and 7.754E+11).
Of the total 11 patients getting infected, 3 were operations on obstructed biliary tract where the bile grew Gram negative organisms which were also isolated from the wound discharge. Of the 3 frankly contaminated procedures, 2 were colonic perforations and the third was a perforated appendix, all the 3 grew Gram negative organisms. There were 3 patients with incisional hernia and 1 patient with hydrocoele among the clean procedures getting infected. Of these, the wound discharge of patients with incisional hernias grew Staphylococcus aureus while the infected hydrocoele grew Klebsiella aerogenes,
Though antisepsis as a method of prevention of post-operative wound sepsis has been in use for nearly a century, no agreement exists as to the best method for the preparation of the patients' skin and the surgeons' hands. A large amount of research done in the recent years has thrown doubt on many of the traditional concepts. It has been shown that the mere application of an antiseptic on the operation site will cause a 99% reduction in the colony counts of organisms on the skin and that this reduction persists for two hours or more. Dineen has shown that a five minute scrub is as effective as a ten minute one in effectively reducing the number of microorganisms on the hands. However, in a recent survey of 113 hospitals in the United Kingdom it is seen that the time for antiseptic application varied from between less than one minute to more than ten minutes. It is difficult to opine as to the optimal contact time needed to get a relatively germ free operation site. The position is complicated by the fact that 20% or more cutaneous organisms reside in the deeper layers of the skin and are beyond the reach of antiseptics applied to the surface. It has also been shown that even after effective decontamination of the skin surface, regrowth of organisms occurs from the deeper layers of the skin and that the numbers of skin organisms approached the control levels with passage of time. More disturbingly, the action of vigorous scrubbing may in fact release these organisms onto the surface, thus negating the very concept of skin degerming.
It is generally believed that control of all variables in a clinical setting is difficult in attempts to assess relative efficacy of methods of skin degerming. However, in our trial, the two groups were uniform with regards to the age, sex and the type of procedures performed. The overall infection rate and the proportion of different procedures showing post-operative infections were similar in the two groups. As a matter of fact, the organisms grown in the discharge in patients undergoing clean contaminated and frankly contaminated procedures showed Gram negative organisms which had earlier been isolated in bile or the peritoneal fluid and the wound infection in these patients was probably as a result of contamination during surgery. The cause of post-operative wound infection in clean procedures (4 in this study) was due to infection in subcutaneous haematomas. We have been unable to prove that the old traditional method of scrubbing vigorously for long periods has any advantage over a more simplified method of simply applying antiseptic on the operation site. Therefore we conclude that simple painting of the operation site is an effective as the old traditional ritual of scrubbing for ten minutes.
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