[Matthias.Maiwald@KKH.COM.SG Subject: Re: Pre operative skin prep – orthopaedic joint replacement In-Reply-To:]

Dear Fiona, dear Group,

I am reasonably familiar with the literature about preoperative skin
antisepsis (“skin prep”) and am not aware of any article describing or
supporting this practice. Neither am I aware of any literature arguing
against it. If there is no description or literature supporting it, this
would clearly make it an unproven practice. I am also not aware of a clear
microbiological rationale supporting it.

There is theoretical concern against it. If it is applied for a prolonged
period (there was no time specified in the e-mail), it may lead to softened
skin, analogous to the “washerwomen’s hands”, and this may impair the
natural defence mechanisms of the skin against infection. Again, this is
only a theoretical concern and also remains unproven. (But it would be
analogous to skin shaving on the evening before surgery, which is known to
damage skin and increase surgical site infections).

However, the classical preoperative skin antisepsis is a tried and proven
procedure with many decades of experience behind it and a sound
microbiological rationale supporting it (and now even clinical trials, see
Darouiche et al, NEJM earlier this year). I have always emphasised that if
people try supplementary methods (note that the above appears unproven)
they should not cut down on any of the important aspects of classical skin
antisepsis. These are:

(1) Choice of a good antiseptic, i.e. alcohol compounds for superficial
skin, aqueous compounds for mucous membranes.

(2) Repeated application (e.g. 3 x) with some friction.

(3) Sufficient contact time, preferably 5 min in total, before commencing
surgery. Note that no antiseptic or disinfectant kills instantly, all
follows a time-dependent reaction.

(4) When using alcohols, avoiding pooling and wetting of drapes and letting
the antiseptic dry before commencing surgery.

I have heard of a practice whereby inappropriate antiseptics (e.g. aqueous
compounds for superficial skin) are applied, and because the surgeon(s) did
not want to wait for the contact time to pass, wipe the antiseptic away
manually after only about 30 sec and start cutting. This is grossly
negligent.

As far as the question of a suitable alcohol product is concerned, as far
as I am aware, Orion from Western Australia has a suitable one, from memory
70% isopropanol, 2% chlorhexidine, tinted red (magenta). But there may be
more vendors, and I would support the availability of a healthy range of
good, effective products from different vendors.

For a brief article dispelling the unfounded concern about fire risk when
using alcohol skin preps see:

http://www.ncbi.nlm.nih.gov/pubmed/16768711

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 1389
Fax +65 6394 1387

“Wishart,
Michael”
AICALIST@AICALIST.ORG.AU
Sent by: AICA cc
Infexion
Connexion Subject
orthopaedic joint replacement

26/08/2010 06:45
AM

Please respond to
AICA Infexion
Connexion

[Posted on behalf of John Ferguson – Moderator]

Hi Fiona

No evidence to my knowledge to support such a practice!

The elephant in the room is Australian surgeons reliance on aqueous
betadine skin prep in the first place given that the evidence for alcohol
solutions of either betadine or chlorhex is there. We have raised this
with the president of the RACS and hope to get some local usage of chlorhex
/alcohol products. The problem has been identifying a locally marketed
product that has colour dye in it. Has anyone located something to use?

A related elephant is the relative lack of use of preop alcohol skin prep
for surgical staff given its effectiveness, speed and skin friendliness.

Kind regards
John

Dr John Ferguson
Director, Infection Prevention and Control Unit Microbiologist and
Infectious Diseases Physician HUNTER NEW ENGLAND HEALTH Locked Bag 1,
Newcastle, NSW 2310, Australia
tel 61 2 49214422, fax 61 2 49214440

Visit http://www.hicsiganz.org for updates on healthcare infection prevention &
control from around Australia and NZ.

Of Fiona de Sousa
joint replacement

At our facility we have some orthopaedic surgeons who insist that their
joint replacement patients have betadine painted over the relevant area and
then have it wrapped in a sterile drape prior to going to theatre for
surgery.
This process occurs in our day of surgery admission area and poses several
problems including that patients often decide they need to use the
bathroom after the wrap has occurred and in getting out of bed and walking
to the bathroom the wrap often falls onto the floor and then gets picked up
by the patient and put back on.

We have been investigating this practice and not been able to find any
evidence for it but have been assured it is essential. Does anyone have
any evidence in support of betadine wraps? What do other facilities use
for pre operative skin prep for their joint replacement patients?

Kind Regards,

Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
185 Fox Valley Road, Wahroonga, NSW, 2076

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