February 2007 - Volume 1, Issue 1

THE EFFICACY OF METHOD OF SCRUBBING OF OPERATIVE SITE ON POST-OPERATIVE WOUND INFECTION

	Rema Al-Majaly SN
	Rema Al-Majaly, P.O. Box 1834 Amman 11910 Jordan E-mail: remamajaly@yahoo.com

ABSTRACT Objective: to evaluate the efficacy of a method where the antiseptic was merely painted on to the operation site without scrubbing it. Patients and Methods: 68 patients undergoing elective and emergency operations in a single surgical unit have been included in this study. Patients were randomized into two groups: Group A: wherein skin preparation is done by traditional methods, i.e.; scrubbing the site for a full ten minutes with a solution containing 0.75% chlorhexidine and 1.5% cetrimide followed by wiping the area dry and the application of 1% iodine in 70% spirit. 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. Results: The mean age and sex distribution of patients was not significantly different between the two groups and when compared to the total. Out of 68, forty-six patients had a clean procedure, 11 underwent clean contaminated procedures and in 11, the procedures were for frankly contaminated conditions. The proportion of the type of procedures was not significantly different between the two groups. There were a total of 7 patients who showed evidence of post- operative wound infection (8%). Of these, 4 belonged to group A (8.82%) and 3 to group B (7.42%). The overall infection rate in the two groups when compared was not significantly different. Therefore, the proportion of different procedures getting infected in the two groups was not significantly different. Conclusion: Simple painting of the operation site is an effective as the old traditional ritual of scrubbing for ten minutes

Key words: scrubbing, wound, antiseptics, infection. INTRODUCTION

Mechanical skin preparation is a daily nursing procedure in general surgery. (1) Bathing or showering cleans the skin by mechanical removal of bacteria shed on corneocytes. Bacterial counts are at least as high or higher after bathing or showering with a regular soap than before. Frequent bathing has aesthetic and stress-relieving benefits but serves little microbiologic purpose. Mild, non-antimicrobial soap should suffice for routine bathing. Bathing with an antimicrobial product reduces rates of cutaneous infection and could be beneficial when skin infections are likely or before certain surgical procedures.(2)

The trend toward more frequent washing with detergents, soaps, and antimicrobial ingredients needs careful reassessment in light of the damage done to skin and resultant increased risk for harboring and transmitting infectious agents. More washing and scrubbing are unlikely to be better and may in fact be worse. The goal should be to identify skin hygiene practices that provide adequate protection from transmission of infecting agents while minimizing the risk for changing the ecology and health of the skin and increasing resistance in the skin flora. (3)

The traditional method of pre-operative skin preparation 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 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.

In this prospective randomized study, we evaluate the efficacy of a method where the antiseptic was merely painted on to the operation site without scrubbing it.
MATERIALS AND METHODS

The sample of this prospective study was carried out in Queen Alia hospital. All patients undergoing elective and emergency operations in a single surgical unit 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 no medicated soap and water on the morning of the operation and were issued freshly laundered clothes.

They were then randomized 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.

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 to check 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.
RESULTS

A total of 68 patients were included in the study (52 males and 16 females). Patients were equally randomized to group A (scrub group) and group B (paint group) and each group consisted of 34 patients.

The mean age and sex distribution of patients was not significantly different between the two groups and when compared to the total.

Out of 68, forty-six patients had a clean procedure, 11 underwent clean contaminated procedures and in 11, the procedures were for frankly contaminated conditions. The proportion of the type of procedures was not significantly different between the two groups.

There were a total of 7 patients who showed evidence of post- operative wound infection (8%). Of these, 4 belonged to group A (8.82%) and 3 to group B (7.42%). The overall infection rate in the two groups when compared was not significantly different. Of 4 patients in group A were infected, one had clean procedures, 2 clean contaminated, and one frankly contaminated procedure. Of 3 incidences of infections in group B, one followed clean procedures, one followed a clean contaminated procedure and one followed frankly contaminated procedures.

Therefore, the proportion of different procedures getting infected in the two groups was not significantly different.
DISCUSSION

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 (4) 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."

Extensive studies of showering and bathing conducted since the 1960s demonstrated that these activities increase dispersal of skin bacteria into the air and ambient environment(5-7), probably through breaking up and spreading of microcolonies on the skin surface and resultant contamination of surrounding squamous cells. These studies prompted a change in practice among surgical personnel, who are now generally discouraged from showering immediately before entering the operating room. Other investigators have shown that the skin microflora varies between persons but is remarkably consistent for each person over time. Even without bathing for many days, the flora remains qualitatively and quantitatively stable. (8-10)

In 11 studies reviewed by Keswick et al. (11), use of antimicrobial soaps was associated with substantial reductions in rates of superficial cutaneous infections. Another 15 experimental studies demonstrated a reduction in bacteria on the skin with use of antimicrobial soaps, but none assessed rates of infection as an outcome.

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(12). Dineen(13) 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 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(14). It is difficult to opine as to the optimal contact time needed to get a relatively germ free operation site.

For surgical or other high-risk patients, showering with antiseptic agents has been tested for its effect on postoperative wound infection rates. Such agents, unlike plain soaps, reduce microbial counts on the skin (15-17). In some studies, antiseptic preoperative showers or baths have been associated with reduced postoperative infection rates, but in others, no differences were observed (18-20). Whole-body washing with chlorhexidine-containing detergent has been shown to reduce infections among neonates (21), but concerns about absorption and safety preclude this as a routine practice. Several studies have demonstrated substantial reductions in rates of acquisition of methicillin-resistant Staphylococcus aureus in surgical patients bathed with a triclosan-containing product(22,23). Hence, preoperative showering or bathing with an antiseptic may be justifiable in selected patient populations.

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 (2 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.
CONCLUSION

Simple painting of the operation site is an effective as the old traditional ritual of scrubbing for ten minutes.

The old method of prolonged scrubbing the operation site can safely be omitted to a more simplified version.
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