3Joseph Lister ( )Hospitalism: outcomes of pyaemia, septicaemia, erysipelas, hospital gangrene and tetanusOne of the giants of infection controlLaid down the principles of antisepsis in surgeryIn late 1800s, he started to use carbolic acid to clean the operation site before incision.
4Topical antiseptic solution in OT 1. Preoperative skin preparation2. Regional anaesthesia (epidural, spinal, etc)3. Central line insertion4. Hand hygiene
5Topical antiseptic are antimicrobial agents that kill, inhibit or reduce the no. of microorganisms on the skin.Human skin is colonized by a wide variety of microorganisms that may provide a protective mechanism to the host, but also a source of infection.
6Normal skin flora Transient: Resident: contracted from the environment or from other peoplethrive in the environment of sweat, dirt and oilcan be easily removed by soap and water.Resident:live in the skin pores and stratum corneumcontinually work towards the skin surfaceDifficult to remove and require antimicrobial agents with residual action to be effective
7Topical antiseptic are active against both resident and transient flora by both mechanical and chemical action.Apply enough pressure and friction to remove dirt, debris and microbes. (except superficial malignancy, areas of carotid plaque)Common antiseptics: Alcohol, Iodine and iodophors, Chlorhexidine
8Alcohol Protein coagulation and denaturation Alcohol-mediated disruption of cytoplasmic integrity, cell lysis and interference with cellular metabolism100% alcohol is not effectiveit deprives bacterial cell walls of waterinduce the formation of impermeable protein layers which prevent the alcohol from penetrating in to the cell
9Most common concentration: 70% Alcohol is defined by FDA as having one of the following active ingredients:Ethyl alcohol, 60-95% by volume in aqueous solutionIsopropyl alcohol, % by volume in aqueous solutionMost common concentration: 70%Effective, less dessicating, less expensive
10Advantages Onset of action is most rapid, 10-15 sec Broad antimicrobial spectrum:Excellent bactericidal effect on G+, G-Effective against tubercle bacillus, fungi and virus (certain enveloped viruses: HSV, HIV, influenza virus, RSV)Not sporicidal, poor activity against certain nonenveloped viruses (e.g. poliovirus, enterovirus, HAV, rotavirus)Alcohol antiseptic has been used since 1930s and there have been no reports of alcohol resistant bacterial strains
11Disadvantages No residual activity Effectiveness is reduced by organic materials such as blood, mucus, excretaVolatility and Flammability﹡Drying of skin, allergic contact dermatitisEmollients, may enhance the antimicrobial activityToxic reactions have been reported in children after sponge bathing with isopropyl alcohol to reduce fever ( s). The vapors may be absorbed through the lungs and cause acute poisoning.
13Iodine and iodophorsTincture of iodine was used as early as 1839 by French war surgeon who treated battle wound during the Civil WarAction:Iodine molecules rapidly penetrate the cell wall of microorganismsinactivate cell s by forming complex with amino acid and unsaturated fatty acidsImpaired protein synthesis, alteration of cell membraneMost effective concentration is 1-2%Cause stinging and irritation, discolorationMust be removed with 70% alcohol after drying
1410% povidone-iodine contains 1% iodine Iodophors: solutions in which iodine is chemically bound to polymer carrier (complexing agents of high molecular weight) e.g. polyvinylpyrrolidonePovidone-iodine = BetadineWater soluble, less staining, less irritating to skin, eye and mucous membraneAllows slow and continuous release of free iodine which determines the antimicrobial activity10% povidone-iodine contains 1% iodine
15Broad spectrum of bactericidal activity Onset:iodophors require ~2 min of contact time to allow release of free iodineafter driedBroad spectrum of bactericidal activityEffective against G+, G-, tubercle bacillus , fungi, virus and certain spore forming bacteria (e.g. clostridia, Bacillus spp.)Not sporicidal in concentration used in antiseptic
16Antimicrobial activity is affected by Rapidly neutralized in the presence of organic materials such as blood, mucus, sputum, urine, faeces, etcAntimicrobial activity is affected bypH (~6)temperature (esp sporicidal activity is markedly temperature-dependent, ↑temp → ↑activity)exposure time, conc of total available iodine, etcGreater activity when the cpd is in dry stateSome residual effectIf washed away, min (except 1 study: 6 hrs)Bacteriostatic effect as long as on the skin
17To dry or not to dry???Wipe the skin dry after apply the antiseptic agent to allow adherence of disposable adhesive drapesKutarski, Grundy. To dry or not to dry? An assessment of the possible degradation in efficiency of preoperative skin preparation caused by wiping skin dry. Annuals of the Royal College of Surgeons of England (1993) vol 75,Skin flora were obtained from subjects at 5, 30, 60 and 120 minNo significant difference in the reduction of baseline count of skin flora between wiping the agent off after 30 sec of application and leaving it to dryAuthor suggested a longer period of application time may be worthwhile , particularly where infection would prove disastrous, e.g. implanting prostheses
18Povidone-iodine related chemical burns 24/F, R hand flexor tendon repair (2hrs)Preparation ran down the patient’s arm and absorbed by the padding under the tourniquet cuff
1945 yrs old, epidural anaesthesia for femoro-popliteal bypass graft, gauze soaked in povidone-iodine antiseptic solution and was then covered with occlusive transparent waterproof dressing blistered area in the shapeof the gauze at the back
20PI after closed and prolonged exposure can damage the skin over bony prominence, pressure points, underneath an area constricted with a tourniquet dressing or bandageRecommendations:Skin must not be abraded excessively before the final skin preparation solution is appliedThe agent should not be allowed to pool and become trapped under the tourniquet or the torso of the patientThe agent should be allowed to dry before the patient is draped.
21Transcutaneous iodine absorption Topical application of PI in burn patientsrenal failure, metabolic acidosis, hypernatraemia, hyperosmolarity, hypothyroidismHypothyroidism in infantsSkin is very thin and permeableHigh plasma iodine conc transient inhibition of thyroid hormone production, ↓serum thyroxine level (Wolff-Chaikoff effect)Usu lasts only 48hrs, even if the plasma iodine level remain highProlonged hypothyroidism esp in preterm infantsRecommendations:Avoid iodine containing antiseptic in infants<3mths oldIodine should be washed off with sterile saline solution
23Chlorhexidine gluconate (CHG/ Hibitane) Cationic bisbiguanideAction:attachment, disruption of cytoplasmic membranesprecipitation of cellular contentsBroad antimicrobial spectrumGood activity against G+Less activity against G-, fungiPoor activity against tubercule bacilliNot sporicidalIn vitro activity against enveloped virus (HSV, HIV, CMV, influenza, RSV)Less activity towards non-enveloped virus (rotavirus, adenovirus, enterovirus)
24Introduced to Europe in 1950s and US in 1970s Bacterial resistance not common, limited to some resistant strains of Pseudomonas, Proteus, Staphylococcus aureusAntimicrobial activity is not affected by the presence of organic material∵cationic ∴activity reduced by natural soaps, inorganic anions, nonionic surfactants, hand cream containing anionic emulsifying agentspH dependent (5-8), if pH above 9 precipitation of active component
25Good residual activity Onset: 3-5 minGood residual activityIt binds to skin and mucous membrane and remain active for at least 6 hrsNot absorbed through skin , low irritancy potentialShould not come into contact with eyes, meninges (neurotoxic), middle ear (ototoxicity)
26Allergy/ Anaphylaxis to chlorhexidine Most of the case reports from Japanese literatureApplication to skin, mucous membrane, chlorhexidine-sulphadiazine-coated central venous catheter(In our ICU, the antibiotic-coated central venous catheter is minocycline/ rifampicin coated)
27Summary agent mechanism of action G+ G- MTB Fungi virus Rapidity of actionResidual activityAlcoholDenatureprotein+++++Rapid10-15 snoneCHGDisrupt cell membrane-+Intermediate3-5 minIodine/iodophorOxidation/ substitution by free iodine2 minsome
29Alcohol based antiseptic solution low concentration (0.5-1%) CHG is added to alcohol (70%)Combination of Alcohol and PIAdvantages:Rapid action of alcoholPersistent action of CHGDecrease the drying time
30Operating theatre fire and alcohol based antiseptics
31Case reportsBarker S, Polson J. Fire in the operating room: a case report and laboratory study. Anesth. Analg. 2001; 93: 960-5Fong E, et al. Diathermay and alcohol skin preparations – potential disastrous mix. Burns 2000; 26: 673-5Chang BW, et al. Patient fire safety in the operation room. Plast. Reconstr. Surg. 1994; 93:Magruder G, et al. Fire prevention during surgery. Arch. Ophthalmol. 1970; 84: 237Briscoe C, et al. Infammable antiseptics and theatre fires. Br. J. Surg. 1976; 63: 981-3Nicholson M. Comments. Anesth. Analg 1972; 51: 646Waitemata Distric Health Board. Report into operating theatre fire accident, 17 Aug Witemata Distric Health Board Final Report. New Zealand; Waitemata Hospital, 2002.Toother R, et al. Surgical fires and alcohol-based skin preparations. ANZ J Surg.2001: 74: ………………………………..
3232/F, R axillary abscess for I&D under GA Diathermy is usedUpon removal of surgical drapes, the underlying incontinence pad was on fire, curling up at the edges (alcohol burns with an invisible flame)large area of full thickness burn involving mainly the dependent sites where the solution had pooled soaking the incontinence pad
3317/F, LSCS under epidural anaesthesia 0.5% CHG with 70% alcohol was used to prepare the abdomenDiathermy was used“woomph” noise was heardPatient complained of heat and the anaesthetist felt the heat and saw a flame/shimmerFire was put out with fire and CS completed with birth of a healthy babyThe mother suffered 12-16% full thickness burns to her inner thighs and both flanksdue to pooling of alcohol-based skin antiseptic underneath the adhesive surgical drapes which produced alcohol vapour which was ignited by a spark from diathermyNo oxygen supplement is given
35RecommendationsAlcohol-based solutions are not recommended for skin preparation in the presence of ignition source ( electrocautery unit, laser)Any alcohol based solution should be clearly labelledRun-off and pooling of alcohol based antiseptic should be avoided byUsing minimum amount necessaryAllowing solution to dry completely prior to drapingPreparation that contains dye are recommended because they make it easier to see what skin has been painted less likely to use excessive amt and poolingTemporary absorptive sheets around the surgical site while using alcohol based solution and removed after use
36Don’t put diathermy and laser foot pedals side by side The drying time for skin preparation might need to be longer than the manufacturer’s recommendation (usu 2-3 min), 5 min might be preferableElectrosurgical instruments should be used on the lowest power setting to minimize the risk of sparking and excessive temperaturesDon’t put diathermy and laser foot pedals side by sideDon’t leave diathermy in the quiver each time after useThe creation of oxygen rich atmosphere should be avoidedNot to create O2 tents by placing drapes over nasal cannula or oxygen maskIn event of fire , oxygen and nitrous oxide supply should be ceased immediately
381. Surgical site infection (SSI) An audit of pre-operative skin preparative methods practised by the surgeons in Northern Ireland in 2005
39CDC guideline for prevention of surgical site infection, 1999 Use an appropriate antiseptic agent for skin preparation. Category IB (Strongly recommended for implementation and supported by some experimental, clinical or epidemiological studies and strong theoretical rationale)….The iodophors, alcohol-containing products and chlorhexidine gluconate are most commonly used agents….….No studies have adequately assessed the comparative effects of these preoperative antiseptics on SSI risk in well-controlled, operation specific studies….
40The Cochrane Database of Systematic Reviews Preoperative skin antiseptic for preventing surgical wound infections after clean surgery (2004)There is insufficient evidence from randomised trials to support or refute the use of antiseptic preparation of skin at operative sites, or of one antiseptic over another.Only one RCT (Berry 1982) demonstrated a significant difference in infection rates between two different antiseptics (in favour of CHG over iodine)
41371 clean operations Results: Limitation: Berry A, et al. A comparison of the use of povidone-iodine and chlorhexidine in the prophylaxis. J. of Hospital infection 1982; 3 (1):371 clean operationsResults:Gp1. povidone-iodine 10% in alcohol28/176 , 15.9%Gp2. chlorhexidine 0.5% in spirit8/195, 4.1%Limitation:Lack of extensive FU, underestimate the infection rates
42Hibbard, et al. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: A Review. J. of infusion nursing 2005, 28 (3):CHG+IPA provided the best immediate, persistent, cumulative antimicrobial activityOstrander, et al. Efficacy of surgical preparation solutions in foot and ankle surgery. J. Bone joint Surg Am 87: , 2005.ChloraPrep ( 2% chlorhexidine and 70% IPA) was most effective for eliminating bacteria from the forefoot prior to surgery, when compared with DuraPrep (0.7% iodine + 74% IPA) or 3% chloroxylenolBibbo C, et al. Chlorhexidine provided superior skin decontamination in foot and ankle surgery. Clinical orthopaedics and related research 438: , 2005.
432. Epidural catheter insertion A survey of fellows of ANZCA with a special interest in obstetric practice, about their beliefs regarding aseptic precautions for insertion of epidural catheter in labour ward in 2002
44Mechanisms of epidural infection: Skin flora introduced either at the time of puncture or bacterial migration along a catheter or needle tract(soiling of the back by amniotic fluid, urine and feces during labour and delivery ↑catheter contamination)Contamination of drug or materialHaematogenous spread from another site of infectionCatheter colonization arising from clinicians’ and nurses’handling of syringes and solutions, via catheter hub
45Clevenot D, et al. Critical review of the literature concerning the comparative use of two antiseptic soultions before intravascular or epidural catheterization. Ann Fr Anesth Reanium 2003 Nov; 22(9):Chlorhexidine in alcoholic solution seems more efficient than povidone iodine in aqueous solution in the clinical setting.The place of povidone iodine in alcoholic solution, whose performances on the healthy skin are similar to those of alcoholic chlorhexidine, is being in evaluation.
46Birnbach, et al. Comparison of povidone iodine and DuraPrep (iodophor in IPA) for skin disinfection prior to epidural catheter insertion in parturients. Anesthesiology 2003; 98(1):
48Explanation: Alcohol provides rapid antisepsis Long lasting effect: Duraprep, when placed on skin, produces a film of disinfectantThis film resists being washed away by fluids and blood
49Kinironsm et al. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children. Anesthesiology 2001; 94:Alcoholic solution of 0.5% chlorhexidine vs aqueous solution of 10% povidone iodine
51Catheter inserted after skin preparation with chlorhexidine were one sixth as likely and less quickly colonized as catheters inserted after skin preparation with povidone iodine
52Sakuragi, et al. Bactericidal activity of skin disinfectants on MRSA Sakuragi, et al. Bactericidal activity of skin disinfectants on MRSA. Anesth Analg 1995; 81:Most frequently detected organism in the normal human skin flora is S. epidermidis (65-69%).The prevalence of S. aureus is 1-2% but is the most common organism in epidural abscess.
543. Central line insertion Two main routes by which intravascular devices become contaminatedIntraluminal contamination:consequence of improper handling of the catheter hub at the time of connection and disconnection of the administration setMost common origin after the first week of catheter placementTo prevent this, strict asepsis must be observed in hub and fluid handling
55Extraluminal contamination: Bacterial invasion from the catheter entry site along the external surface of the catheterBacteremia during the week following catheter placementPrevented by appropriate skin disinfection and the adoption of maximal antiseptic barriers at the time of catheter insertion
56Chaiyakunapruk, et al. Chlorhexidine compared with povidone-iodone solution for vascular catheter-site care: A Meta-analysis. Ann Intern Med 2002; 136:
57The overall risk ratio for catheter colonization in chlorhexidine group compared with povidone-iodine is 0.49Chlorhexidine rather than povidone-iodine can reduce the risk for catheter-related bloodstream infection by approximately 50% in hospitalized patients who require short-term catheterization.
58Subset analyses of aqueous and nonaqueous solutions showed similar effect sizes, but only the subset analysis of the five studies that used alcoholic solution produced a statistically significant reduction in catheter-related bloodstream infection.Few studies used chlorhexidine aqueous solution
59Parienti, et al. Alcholic povidone-iodine to prevent central venous catheter colonization: A randomized unit-crossover study. Crit care med 2004; 32(3):
60CDC guidelines for the prevention of intravscular catheter-related infections, 2002 Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changesAlthough a 2% chlorhexidine based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used.Allow the antiseptic to remain on the insertion site and to air dry before catheter insertionAllow povidone iodine to remain on the skin for at least 2 min or longer if it is not yet dry before insertionDo not apply organic solvents (e.g. acetone and ether) to the skin before insertion of catheter or during dressing changes
61NICE (National Institute for Clinical Excellence) guideline for infection control, 2003 Catheter site care:An alcoholic chlorhexidine gluconate solution should be used to clean the catheter site during dressing changes, and allowed to air dry.An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendation prohibit the use of alcohol with the product.
62ConclusionSkin antisepsis plays an important role in infection control and prevention of nosocomial infection (e.g. surgical site infection, epidural infection, catheter related infection, etc)An understanding of the properties of different antiseptic solutions is needed to facilitate the selection and proper use of them.
63It should be remembered that antiseptic solution is only a small part of infection control. Aseptic techniques such as cap, gowning, glove, mask, proper scrubbing, etc are also very important.
65My opinion Ideal antiseptic solution does not exist The current evidence seems to favour the alcohol based antiseptic solution (esp alcoholic chlorhexidine)If alcohol based solution is avoided in view of OT fire, povidone-iodine is an alternative.The effect of aqueous chlorhexidine is unsure as most of the studies involve alcoholic chlorhexidine.