Preoperative Topical Antiseptic Measures to Prevent Nosocomial Infection
By Shawn Gentry
It has been well established that measures to prevent nosocomial infections begin well before the surgical procedure. During the preoperative phase, hair removal and the proper use of topical antiseptics for bathing, hand scrubbing, and site preparation are considered important in reducing the opportunity for a nosocomial infection.
Some of the preoperative measures performed in or near the operating room are helping to keep the postoperative hospital stay short and uneventful, as related to nosocomial infections. First, it is now recommended to avoid hair removal or, if necessary, remove hair with clippers or depilatories rather than a razor. Studies indicate that shaving with a razor can injure the skin and increase the risk of infection. If shaving is necessary, it should be performed immediately before the operation and followed with the use of a preoperative antiseptic. Secondly, the skin at the operative site is thoroughly cleaned to remove superficial flora, soil, and debris before the operation to reduce the risk of contaminating the wound with a patient's skin flora. Finally, immediately before the surgery, a preoperative antimicrobial skin preparation is applied to the patient's skin to kill or inhibit more adherent, deep, resident flora. A patient preoperative skin preparation is defined by the U.S. Food and Drug Administration (FDA) as "a fast-acting, broad-spectrum and persistent antiseptic containing preparation that significantly reduces the number of micro-organisms on intact skin."
The list of antimicrobial agents commercially available as principal active ingredients for use in patient preoperative skin-preparation products is relatively short and currently includes alcohols, chlorhexidine gluconate (CHG), and iodophors such as povidone iodine (PVPI). Only two of these antimicrobial classes, 1) alcohols (specifically ethyl alcohol and isopropyl alcohol) and 2) iodine and iodophors, are currently classified Category 1 (safe and effective) and allowed for patient preoperative skin preparation under the FDA's Tentative Final Monograph for Healthcare Antiseptics.
While very effective antimicrobial agents when used in sufficient concentration (60-90%), alcohols appear to act by rapid denaturation of biomolecules (DNA, RNA, lipids, etc.) essential to microbial growth and development. Alcohols prove very effective against a broad spectrum of microorganisms, including gram-negative and gram-positive bacteria, fungi, and viruses, including the HIV, hepatitis B, and respiratory syncytial viruses. Alcohol application provides the fastest and greatest reduction in microbial counts on the skin. A one-minute immersion, or scrub, with alcohol proves as effective as four- to seven-minute applications of other antiseptics and requires hours for the bioburden to return to pre-scrub levels. Bacterial resistance to alcohols at high concentrations is extremely low to almost non-existent.
With respect to their use in surgical site preparation or skin antisepsis, three alcohols have been studied extensively: ethyl alcohol, isopropyl alcohol, and n-propyl alcohol. Studies conclusively show greater antimicrobial effectiveness for n-propyl alcohol than for isopropyl or ethyl alcohol at concentrations below 60 percent; however, at higher concentrations, structural differences become less of a factor in relative efficacy. Safety profiles for these alcohols have been well characterized, and although toxicity has been reported when sponging febrile children with isopropyl alcohol, alcohols are generally considered among the safest antiseptics for topical use.
In Europe, alcohol-based preparations, recognized as having greater immediate
antimicrobial action than all other active ingredients, are often used for
surgical preparation of the hands. Until very recently, alcohols have not been
widely used in the United States as surgical scrub ingredients because, despite
their excellent, quick, and thorough antimicrobial action, they do not have any
significant detergency for the removal of organic debris or antimicrobial
persistence in the stratum corneum. They also tend to be very drying to the
skin. However, very recent developments have produced at least one surgical
scrub product (TriSeptin®) that while alcohol-based, has detergent
action, contains emollients for hand conditioning, and other factors that
produce antimicrobial persistence beyond 24 hours. These same properties have
been incorporated into a surgical site preparation. The resulting suspension is
skin friendly, rapid acting, long-lasting, and fast drying.
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