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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.
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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.
Patients 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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