| The information in this column is intended for | | | | trial, there was a 58 percent overall reduction in the |
| informational purposes only, and does not constitute | | | | relative risk of SSIs among the "experimental group" |
| medical advice or recommendations by the author. | | | | of patients when compared to the patients who |
| Please consult with your physician before making any | | | | received only placebo ointment and placebo soap. |
| lifestyle or medication changes, or if you have any | | | | The benefit of preoperative treatment with |
| other concerns regarding your health. | | | | mupirocin ointment and chlorhexidine soap was even |
| Infections following surgery in the United States | | | | more pronounced for SSIs involving deep body |
| occur in approximately 3 to 5percent of all cases, and | | | | spaces, in this study: the relative risk of deep body |
| in more than 10 percent of certain types of | | | | space SSIs was reduced by 79 percent in the |
| operations. In view of these statistics, surgical site | | | | "experimental group" of patients. Therefore, the |
| infections (SSIs) are a major public health problem | | | | results of this powerful prospective clinical trial |
| throughout the world. On average, patients in the | | | | suggest that SSIs following elective surgery can be |
| United States who develop an SSI will remain in the | | | | significantly reduced by, first, testing patients for |
| hospital for an additional week, resulting in an average | | | | evidence of colonization with Staphylococcus aureus |
| of more than $25,000 in additional healthcare costs | | | | bacteria and, secondly, by "decolonizing" the nasal |
| per affected patient. Patients who develop SSIs are | | | | passages and skin of already-colonized patients with |
| also 60 percent more likely to be admitted to the | | | | antibacterial ointment and soap, respectively. |
| ICU, and are twice as likely to die, when compared | | | | Many hospitals already selectively apply nasal cavity |
| to patients who do not develop SSIs following | | | | testing for MRSA (either before or following surgery), |
| surgery. Moreover, at a time when profound changes | | | | and recommend a shower with chlorhexidine soap |
| in the United State's health care system are being | | | | prior to surgery. The results of this important public |
| proposed to control skyrocketing health care costs, | | | | health study suggest that the incidence of SSIs can |
| SSIs are estimated to add an additional $10 billion in | | | | probably be further lowered by more rigorous and |
| national health care costs, annually. In addition to the | | | | more universal preoperative screening programs for |
| economic costs associated with SSIs, serious | | | | nasal Staphylococcus aureus (including both MRSA |
| infections following surgery often cause considerable | | | | and non-MRSA Staphylococcus aureus) directed at all |
| suffering among affected patients; and in severe | | | | patients who are undergoing elective surgery. |
| cases, SSIs can also result in permanent disability or | | | | The second, and related, study evaluated the impact |
| death. | | | | of two different preoperative skin prep solutions on |
| The known causes of SSIs are complex and multiple | | | | the incidence of SSIs. |
| and, therefore, no single or simple solution is capable | | | | For decades, now, iodine-based skin cleansing |
| of eliminating all cases of SSIs. However, there is | | | | solutions have been applied to skin surfaces just prior |
| ample research data available suggesting that a | | | | to the start of surgery, in an effort to kill |
| number of opportunities exist whereby the risk of | | | | skin-surface bacteria that can lead to SSIs. While |
| SSIs can be further reduced. For example, one major | | | | these traditional iodine-based antibacterial skin prep |
| (and preventable) cause of potentially life-threatening | | | | solutions are active against many bacteria and fungi |
| SSIs is the increasing prevalence of antibiotic-resistant | | | | that are known to cause SSIs, their antibacterial and |
| strains of bacteria that have developed following | | | | antifungal activity rapidly dissipates after being applied. |
| decades of excessive and inappropriate antibiotic use. | | | | Newer surgical skin prep agents that contain alcohol |
| Among these resistant bacteria, few have raised | | | | and chlorhexidine have been shown by recent |
| more concern than methicillin-resistant Staphylococcus | | | | research studies to not only have a wider spectrum |
| aureus (more commonly known by its acronym, | | | | of activity against skin bacteria and fungi than |
| MRSA). MRSA is capable of causing limb- and | | | | traditional iodine-based prep solutions, but these |
| life-threatening infections, particularly in very ill | | | | newer surgical prep solutions also sustain their |
| patients, and in the very young and very old. When I | | | | antibacterial and antifungal activity over a much |
| began my medical career, more than 20 years ago, | | | | longer duration than their iodine-based counterparts. |
| MRSA was an exceedingly rare cause of bacterial | | | | In this new prospective, randomized clinical research |
| infections. When MRSA first began to appear, this | | | | study, 849 patients undergoing elective surgery were |
| bacterium primarily caused infections among seriously | | | | randomized to one of two groups. One group of |
| ill hospitalized patients, and was rarely a source of | | | | patient volunteers underwent preoperative skin |
| infection among generally healthy nonhospitalized | | | | preparation with a commercially available |
| patients. | | | | chlorhexidine-alcohol solution, while the second group |
| In a landmark study by the Centers for Disease | | | | was randomized to undergo skin preparation with the |
| Control, and published in the Journal of the American | | | | traditional povidone-iodine solution. |
| Medical Association in 2007, a remarkable 58 percent | | | | Following surgery, 16 percent of the patients who |
| of invasive infections caused by MRSA in 2004 and | | | | had their skin prepped with povidone-iodine solution |
| 2005 occurred in nonhospitalized patients, while 27 | | | | developed SSIs within 30 days of surgery, while just |
| percent of MRSA infections arose among hospitalized | | | | under 10 percent of the patients who received the |
| patients. This tectonic shift in the epidemiology of | | | | chlorhexidine-alcohol skin prep solution subsequently |
| MRSA (and other emerging strains of | | | | developed SSIs. (This 41 percent reduction in the |
| antibiotic-resistant bacteria and fungi, as well) has | | | | relative risk of SSIs was found to be highly |
| grave implications for preventing SSIs, as the | | | | statistically significant.) Although use of the |
| majority of SSIs are known to arise from the surgical | | | | chlorhexidine-alcohol skin prep, alone, did not appear |
| patient's own native bacteria. | | | | to protect against deep organ-space infections (when |
| Two important new studies related to SSI | | | | compared with the use of povidone-iodine skin prep |
| prevention, and just published in The New England | | | | solutions) in this study, both superficial and deep SSIs |
| Journal of Medicine, offer important new ammunition | | | | of the surgical incision were significantly reduced |
| in the ongoing fight against potentially deadly SSIs. | | | | following use of the chlorhexidine-alcohol skin prep |
| In the first study, from the Netherlands, patients | | | | solution. In this study, the use of a |
| being admitted to the hospital for elective surgery | | | | chlorhexidine-alcohol prep solution cut the risk of |
| were tested for the presence of Staphylococcus | | | | superficial incisional infection by one-half, while deep |
| aureus bacteria in their nasal passages. In this | | | | incisional infections were reduced threefold. Thus, the |
| prospective, randomized, placebo-controlled, | | | | use of chlorhexidine-alcohol skin prep solutions, just |
| double-blind, multi-center clinical research trial, 6,771 | | | | prior to making the incision, was associated with a |
| patients were screened for the presence of nasal | | | | highly significant reduction in the incidence of both |
| Staphylococcus aureus, and 1,251 of these patients | | | | superficial and deep infections of surgical incisions |
| were confirmed to be nasal carriers of this bacterium. | | | | when compared to traditional iodine-based prep |
| A total of 917 of these patients were subsequently | | | | solutions. |
| enrolled into this clinical research trial. These 917 | | | | Taken together, these two very important |
| patients were then divided into an "experimental" | | | | prospective randomized clinical research trials offer |
| group and a "control" group, although neither the | | | | clinically valuable lessons for patients, physicians, and |
| patients nor the research assistants in this | | | | hospitals in our crucial quest to drive down the |
| double-blind study were permitted to know which | | | | incidence of SSIs to the lowest achievable level. In |
| group any patient was assigned to until after the | | | | view of the recent and ongoing emergence of highly |
| study had been completed. Patients randomized to | | | | virulent strains of bacteria and fungi that have |
| the "experimental" group were treated, before | | | | become resistant to many of our most powerful |
| surgery, with antibacterial ointment (mupirocin) applied | | | | antibiotic and antifungal drugs, respectively, it is |
| to their nasal passages, and with showers using | | | | imperative that we find new ways to reduce the risk |
| antibacterial soap (chlorhexidine), in an effort to | | | | of SSIs, and particularly new methods that do not |
| eradicate surface bacteria (including Staphylococcus | | | | involve the continued inappropriate or excessive |
| aureus) from their noses and skin. The "control | | | | utilization of broad spectrum antibiotic drugs. |
| group" of patients received identical-appearing nasal | | | | If you are scheduled to undergo elective surgery in |
| ointment and skin soap, but without mupirocin or | | | | the near future, I would advocate that you share the |
| chlorhexidine. | | | | findings of these two clinically important research |
| All study patients were tracked following surgery, | | | | studies with your surgeon (if they are not already |
| and the incidence of SSIs was then analyzed. In this | | | | aware of them). |
| highly-powered randomized, controlled clinical research | | | | |