Preoperative Skin Preparation

No literature met our inclusion criteria for this PICO, therefore, recommendations from other groups and areas of orthopaedic surgery were reviewed.

1. Perioperative nasal and skin (full body) decolonization

S. aureus nasal carriage is associated with subsequent infection in surgical patients. Mupirocin nasal ointment is an effective treatment for the eradication of S. aureus carriage. Some studies have shown benefit with mupirocin nasal application for reducing S. aureus related SSIs in orthopedic surgeries, but the efficacy of eradication has not been definitively demonstrated, as study samples were too small. The positive trend reported, however, should encourage further studies with sufficient power. Until such time, the risk/benefit should be assessed individually on a case-by-case basis.

In the one low quality study in the trauma literature (Urias 2018), a retrospective comparative review was performed of patients undergoing repair of lower extremity fractures who received either (1) a chlorohexidine gluconate (CHG) washcloth bath or solution shower preoperatively alone (pre-intervention group) or (2) nasal painting using povidone-iodine skin and nasal antiseptic (PI-SNA) in addition to the CHG washcloth bath or solution shower preoperatively (intervention group). The pre-intervention group consisted of 930 cases with a 1.1% infection rate (10 SSIs) and the intervention group consisted of 962 cases with a 0.2% infection rate (2 SSIs). This observed difference was statistically significant, p=0.020.

In the General Assembly of the 2nd International Consensus Meeting on Musculoskeletal Infection, a strong consensus (super majority) statement was made that no definitive recommendation can be given regarding the routine implementation of pre-operative S. aureus screening and nasal decolonization protocols because of conflicting literature. In addition, no definitive recommendation can be made as to the role of selective versus universal treatment, although the universal treatment strategy seems to be the most cost-effective approach and easiest to implement (Akesson 2019). This consensus statement was based on moderate evidence.

In the WHO evidence-based recommendations for the prevention of SSIs, the panel made a conditional recommendation based on moderate quality evidence that patients undergoing orthopaedic surgery who are known nasal carriers of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate body wash (Allegranzi 2016).

2. Preoperative showering or bathing

Preoperative whole-body bathing is a good clinical practice to ensure that the skin is clean before surgery and to decrease the bacterial burden. Either a plain or antiseptic soap can be used for preoperative bathing, however, current evidence is insufficient to provide a recommendation on the use of CHG for the purpose of reducing SSIs.

In the General Assembly of the 2nd International Consensus Meeting on Musculoskeletal Infection, a strong consensus (super majority) statement was also made that pre-operative skin cleansing at home prior to orthopedic surgery does have a role in the reduction of subsequent SSIs and periprosthetic joint infections (PJIs). Specifically, CHG bathing/wipes have been shown to have excellent results in preventing PJIs/SSIs (Atkins 2019). This consensus statement was based on moderate evidence.  

In the 2017 Centers for Disease Control and Prevention Guideline for the prevention of SSIs, a strong recommendation was made based on accepted practice (Category IB) to advise patients to shower or bathe (full body) with soap (anti-microbial or non-anti-microbial) or an antiseptic agent on at least the night before the procedure (Berrios-Torres 2017).

In the WHO evidence-based recommendations for the prevention of SSIs, the panel made a conditional recommendation based on moderate quality evidence that good clinical practice requires that patients bathe or shower before surgery, and that either a plain or anti-microbial soap can be used for this purpose (Allegranzi 2016).

3. Surgical skin preparation

Standard practice in the management of extremity fractures includes sterile technique and surgical skin preparation with an antiseptic solution. The antiseptic solutions kill bacteria and decrease the quantity of native skin flora, thereby reducing the risk of SSI. Although use of antiseptics for surgical skin cleaning is recommended, the type of antiseptic agent is disputed. Therefore, the only consistent consensus recommendation in the literature has been the inclusion of an alcohol-based antiseptic agent in any skin preparation.

In the General Assembly of the 2nd International Consensus Meeting on Musculoskeletal Infection, a strong consensus (super majority) statement was made that there appears to be no differences between various surgical skin preparation agents (CHG versus povidine-iodine) in reducing the risk of SSI in patients undergoing orthopaedic procedures, as long as isopropyl alcohol is part of the preparation (Atkins et al. 2019).  This consensus statement was based on limited evidence. The authors noted that an ideal solution has yet to be identified for surgical site skin preparations, but there is an overall consensus that the skin preparation solution should contain alcohol.

In the 2017 Centers for Disease Control and Prevention Guideline for the prevention of SSIs, a strong recommendation was made based on high-quality evidence (Category IA) that pre-operative skin preparation should be performed with an alcohol-based antiseptic agent, unless contraindicated (Berrios-Torres 2017).

In the WHO evidence-based recommendations for the prevention of SSIs, the panel made a strong recommendation for use of alcohol-based antiseptic solutions that are based on CHG for pre-operative surgical site skin preparation in patients undergoing surgical procedures, based on low to moderate quality of evidence (Allegranzi 2016).

Benefits & Harms

The potential benefit of pre-operative skin preparations is prevention of surgical site and deep infection. The potential harms of pre-operative skin preparations include skin reactions or allergies (including anaphylaxis), mupirocin resistance, and microbiome disturbances. More specifically, alcohol-based solutions should not be used on neonates or come into contact with mucosa or eyes, and caution should be exercised because of their flammable nature. CHG solutions can cause skin irritation and must not be allowed to come into contact with the brain, meninges, eye, or middle ear. Alcohol based antiseptics are not recommended for open wounds or those with related allergy.

Outcome Importance

Prevention of SSIs is of primary importance. Development of surgical site or deep infection after major extremity trauma can lead to severe morbidity, prolonged hospitalization and significantly increased utilization of healthcare resources. 

Cost Effectiveness/Resource Utilization

Skin preparation with an antiseptic and preoperative bathing with soap are simple, inexpensive and widely available measures. Mupirocin is readily available and although it is a relatively expensive drug, application is easy. The cost of nasal decolonization, pre-operative skin cleansing prior to surgery, or surgical skin preparation is significantly less than what is required for treatment of surgical site or deep infection. 

Acceptability

Highly acceptable with very few contraindications.

Feasibility

While seemingly feasible, the treatment of major extremity trauma is frequently not an isolated entity and may not always be the most pressing issue in the setting of severe trauma. It is important that the healthcare professionals responsible for the musculoskeletal care of patients with major lower extremity trauma be aware of and advocates for the appropriate use of pre-operative skin preparation techniques, including nasal decolonization, pre-operative skin cleansing prior to surgery, and surgical skin preparation. Preoperative skin cleansing and surgical skin preparation are widely used and are well accepted. Nasal decolonization is not universally practiced but is acceptable to most clinicians. 

Future Research

Future research is needed to determine what the optimal approach is for nasal decolonization, pre-operative skin cleansing prior to surgery, and surgical skin preparation in the prevention of deep infections following open fracture with major extremity trauma.  Further studies are needed to determine how these choices may vary within orthopaedic surgery, including based on the type of surgical procedure (urgent trauma versus semi-elective) or in the presence of an open fracture. Examples of questions to further explore in future, large scale studies include: 

1. Which antiseptic agent is superior for prevention of SSIs in fracture patients?
2. Is CHG bathing more effective than soap? What is the optimal timing of bathing and number of baths?
3. Is mupirocin ointment effective in preventing infection with S. aureus in open fracture patients, especially when the standard 5 days application prior to surgery is not a feasible option? Will a different dosing and shorter application period (1-2 days) be of benefit in a subset of patients who have a delay in fracture surgery?
4. Would the combination of bathing with an antiseptic agent and application of mupirocin be more effective than either intervention alone?

References Cited in Rationale

1. Åkesson P, Chen AF, Deirmengian GK, et al. General Assembly, Prevention, Risk Mitigation, Local Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34(2S):S49-S53. doi:10.1016/j.arth.2018.09.053
2. Allegranzi B, Bischoff P, de Jonge S, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e276-e287. doi:10.1016/S1473-3099(16)30398-X
3. Atkins GJ, Alberdi MT, Beswick A, et al. General Assembly, Prevention, Surgical Site Preparation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34(2S):S85-S92. doi:10.1016/j.arth.2018.09.057
4. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017 [published correction appears in JAMA Surg. 2017 Aug 1;152(8):803]. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904
5. Urias DS, Varghese M, Simunich T, Morrissey S, Dumire R. Preoperative decolonization to reduce infections in urgent lower extremity repairs. Eur J Trauma Emerg Surg. 2018;44(5):787-793. doi:10.1007/s00068-017-0896-1