Preoperative Skin Preparation with Chlorhexidine Gluconate Products for Reducing Surgical Site Infections

According to the U.S. Centers for Disease Control and Prevention (CDC), surgeons performed an estimated 16 million surgical procedures in acute care hospitals in 2010 (the latest year for which comprehensive data are available). Patients who undergo surgery are at risk of developing an infection at or near surgical incisions. SSIs can be superficial, involving only the skin, or more serious, involving tissue under the skin, organs, or implanted material. A CDC prevalence survey reported an estimated 157,500 SSIs associated with inpatient surgeries in 2011. National Healthcare Safety Network data, which included 16,147 SSIs after 849,659 operative procedures, reported an overall SSI rate of 1.9% between 2006 and 2008 (see the articles by Mu et al. and Magill et al. for more information).

Patient-related, surgery-related, and physiologic factors may increase SSI risk. Patient-related factors include diabetes mellitus, existing infection, ischemia secondary to vascular disease or irradiation, low serum albumin concentration, obesity, older age, and smoking. Surgical risk factors include inadequate surgical scrub, inadequate antiseptic skin preparation, and prolonged procedures. Physiologic states during surgery that may increase SSI risk include hypothermia, hypoxia, hyperglycemia, shock, and trauma (see the article by Cheadle, Risk Factors for Surgical Site Infection, for more information).

Despite the availability of evidence-based strategies to reduce SSI risk and advances in infection control practices (e.g., improved operating room ventilation, sterilization methods, barriers, surgical technique, availability of antimicrobial prophylaxis), SSIs remain a significant cause of morbidity, prolonged hospitalization, and death. The mortality rate associated with an SSI is about 3% (see the article by Awad, Adherence to Surgical Care Improvement Project Measures and Post-operative Surgical Site Infection). An estimated 40% to 60% of SSIs are preventable (see the article by Olsen, Prevention of Surgical Site Infections: Improving Compliance with the Surgical Care Improvement Project Measures).

CDC reports that SSIs are widely prevalent and are a prime factor contributing to increased length of hospital stay, patient mortality, and costs (an estimated $3.45 billion to $10.07 in one year) (see the CDC report, The Direct Medical Costs of Healthcare-associated Infections in U.S. Hospitals and the Benefits of Prevention).

Clinicians perform preoperative skin preparation using broad-spectrum antiseptics (e.g., CHG, CHG plus alcohol, PI, iodine povacrylex in alcohol) to reduce microorganisms on the skin at the intended surgical incision site. Skin preparation effectiveness may depend on the antiseptic used and the application method. Each antiseptic preparation has a specific mechanism of action and unique advantages and disadvantages. Thus, a particular antiseptic agent may not be superior to others in all clinical situations. Factors to consider when choosing an appropriate intraoperative skin prep agent include “contraindications, environmental risks, the patient's allergies and skin condition, the surgical site, the manufacturer recommendations for the prep agent, and surgeon preference" (see the article by Zinn et al. ).

Patients may apply antiseptics in the days immediately before surgery, or clinicians may apply these on the day of surgery. Application methods include showering, scrubbing, and swabbing. Patient adherence with at-home preoperative skin preparation recommendations (e.g., showering) should be considered.

CHG is a chemical with broad-spectrum antimicrobial properties that is mainly available in over-the-counter products that reduce bacteria on skin before surgery and injections. These products are available as solutions, washes, sponges, and swabs and have many different brand names. Many CHG products also contain alcohol intended to increase the product's effectiveness. See Table 1 for details on...