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  3. Pre-operative Skin Preparation:factors in the prevention of Surgical Site Infections an international perspective

Pre-operative Skin Preparation:factors in the prevention of Surgical Site Infections an international perspective


Healthcare associated infections continue to cause substantial patient morbidity and incur significant cost to any health service. It has been estimated that at any one time, approximately one in 10 patients in acute hospitals have a healthcare associated infection (DoH/PHLS 1995), with 7.8% of inpatients having acquired one or more healthcare associated infections. Surgical site infections account for 20% of all nosocomial infections (Burke 2003), and approximately 4.2% of surgical operations surveyed in England resulted in an infection (National Surveillance Service 2001). There are many factors that determine whether or not a patient will develop a surgical site infection (Cruse and Ford 1980, Mangram 1999) and many pre and perioperative factors (Briggs 1997).

Factors can be endogenous or exogenous. Studies have shown that the bacteria that cause infections are normally from the patient’s own flora, and it has been estimated that approx 95% post-operative infections are caused by endogenous bacterial contamination (HIS 2003), and that less than 3% of infections are solely due to airborne exogenous micro organisms (Nichols 1982).

This article will consider infection control issues pertinent to the preparation and maintenance of the surgical field in terms of skin preparation and will critically review and analyse the relevant literature and research.

The aim is to discover which is the most effective topical antimicrobial skin preparation in reducing the preoperative bacterial skin counts, and bacterial contamination of the wound during surgery.

UTopical preoperative skin antimicrobials

Topical antimicrobial skin preparations are designed to remove the transient flora and reduce the resident flora. The purpose of preoperative skin preparation is remove soil and transient microorganisms, reduce resident microorganisms, and to inhibit rapid rebound growth of micro-organisms (AORN Standards 1997). The most common pathogen isolated, in clean surgical procedures is Staphylococcus aureus, (Cooke and Taylor 1991)either from the patient’s own flora or the exogenous environment (Nichols 2001).

In the United Kingdom, skin preparation is performed immediately prior to surgery. A choice is made from several different topical antimicrobial skin preparations available, often in an ‘ad hoc’ manner (National Association of Theatre Nurses 2005). Most hospitals will have a skin preparation policy to guide choice. Antiseptic skin preps commonly used in the United Kingdom at this present time are chlorhexidene and iodophores (Povidone Iodine).

In the United States of America, other agents such as isopropyl and ethyl alcohols, triclosan and parachlorometaxylenol (PCMX) are used (Fortunato 2000). In America, generally a different preoperative skin regime is adopted, and this begins 24-48 hours prior to surgery with bathing or showering with an antiseptic solution. Some studies have shown this to be effective in reducing, and maintaining a low level of normal and resident flora, for up to 72 hrs after surgery (Seal & Cheadle 2004).

Garibaldi et al (1988) showed that preoperative showering with chlorhexidene did reduce skin contamination. In a large scale and well-respected study, Cruse and Ford (1980) also showed that preoperative showering with hexachlorphrene (which is different to chlorhexidene) resulted in a lower rate of surgical site infection. In another large-scale study Hayek and Emerson (1988) also found preoperative bathing with chlorhexidene to be effective in reducing postoperative infection rates. Similarly, in a study by Tunevall (1988), a reduction in postoperative infection rates, following three preoperative showers with chlorhexidene, have led to changes in practice, and is now recommended hospital practice throughout Sweden.

As in America, in Sweden patients are encouraged to buy a ‘home-pack’ of chlorhexidene scrub from the pharmacy. It could be argued that appears to be good practice, it involves patients in their own care, raising awareness of infection control, and promoting patient confidence. However, a study by May et al (1993) where patients received preoperative skin preparation twice daily for 48 hrs, it was found that this had no effect on the incidence of post-operative infection rates. Similarly, an earlier study by Earnshaw et al (1989) also failed to demonstrate any benefit in preoperative bathing with chlorhexidene, conversely finding that the wound infection rate were higher. However, these two studies (May et al 1993 and Earnshaw et al 1989) were both very small scale studies, each with a sample size of only 64 patients; and it could be argued that these are too small to be of value compared with the large scale study by Cruse and Ford (1980).

Significantly, the Hospital Infection Society Working Group (2003) does not recommend chlorhexidene showers as being effective, and it is not common practice in the United Kingdom.

Several studies have examined the methods by which skin preparations are applied, in order to find the most efficient method, in terms of efficacy and time savings. Workman (1995) found that after application of Povidone-iodine to the skin, that there was no significant difference in the number of bacterial colonies between the air-drying technique and the blot-drying technique. Similarly effective, is the application of a new Povidone-iodine spray technique (Moen et al 2002.) to the surgical site, which, after 3 minutes was as effective as the normal scrub-paint technique. Because there was no action of skin rubbing in this method, the authors believed that this would minimise trauma caused to the skin and therefore reduce the possibility of infections. This contrasts with a study by Messenger et al (2004) who found in a study of the efficacy of several different skin preparations, that it was the rubbing element of the skin preparation method that produced a significantly greater reduction in bacterial concentrations.

The Hospital Infection Society Working Group (2003) recommends alcoholic solutions as being more effective than aqueous for skin preparation, but that caution should be taken to ensure that the alcohol has dried to prevent ignition from the electrocautery. However, povidone-iodine preparations seem to be more popular then chlorhexidene for surgical incisions site preparation, Mackenzie (1988) suggests there is probably little to choose between the two, judged on their germicidal effects on normal skin.

Whilst iodine is clearly an effective skin disinfectant, it’s the efficacy of it’s action is reliant on the prior removal of skin soiling. In a study by Ostrander et al (2003) found that an effective pre-surgical scrub of the operative area was an important step in limiting surgical wound contamination, and that isolation of incisional site with an iodine impregnate self-adhesive drape was effective adjuvant. This study, whilst a relatively small-scale study (50 consecutive patients) is important. Infections in orthopaedic cases can have very serious repercussions and any measures to prevent this from occurring are worthwhile. The study has opened the door for further research, but it could be argued that to instigate their recommendations, on the basis of this small-scale study can at best be beneficial, and worst be harmless.


Management of the surgical site is crucial to preventing infections. Choice of antimicrobial skin preparation should be based on evidenced-based practice, not on ritual and history.

The choice of skin preparation is usually a personal decision. Chlorhexidene and iodine are both effective topical antimicrobials, with little to choose between them. However, alcoholic based povidone-iodine preparations are more effective that aqueous ones, povidone-iodine preparations are more effective than chlorhexidene for preparation of skin for surgical incisions. It would also appear that preoperative showering with chlorhexidene could be effective in reducing the levels of skin contamination and therefore postoperative surgical site infections. However based on the conflicting evidence, it is very difficult to establish which is the most effective method or application.


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University of Wales
Dr. John Gammon

Dr Gammon is recognised as an international authority on infection prevention and control. Currently, he is a Non -Executive Director of Carmarthenshire NHS Hospital Trust and Deputy Head of the School of Health Science, at Swansea University, Wales, UK. He has practiced as an infection control practitioner for many years and been instrumental in Wales in establishing infection control services. Furthermore he has lead on the establishment infection control courses, and national guidance on hospital and community infection prevention strategies. He has been central to the development of, evidence based, international guidance on patient isolation. His research interests include patient isolation, standard precautions and hand decontamination. He has published a number of research papers and continues to advise the Welsh Government on infection control practice and strategy. He acts as key advisor to a number of commercial companies involved in infection control. His focus of academic interest for the last few years has been the education and professional development of practitioners and specifically infection control practitioners. This has included e-learning course as well as Masters programmes in infection control.