What Should the Minimum Percent of Isopropyl Alcohol Be to Prevent Contamination of an I.v.
Rev Urol. 2009 Autumn; 11(4): 190–195.
Pare Preparation for the Prevention of Surgical Site Infection: Which Amanuensis Is Best?
Abstract
Procedural and surgical site infections create difficult and circuitous clinical scenarios. A source for pathogens is often idea to exist the skin surface, making skin preparation at the fourth dimension of the procedure disquisitional. The most common peel grooming agents used today include products containing iodophors or chlorhexidine gluconate. Agents are further classified by whether they are aqueous-based or alcohol-based solutions. Traditional aqueous-based iodophors, such equally povidone-iodine, are one of the few products that can be safely used on mucous membrane surfaces. Booze-based solutions are quick, sustained, and durable, with broader spectrum antimicrobial activity. These agents seem ideal for longer open up surgeries with the potential for irrigation or surgical spillage, such as cystoprostatectomy, radical prostatectomy, and retroperitoneal lymph node dissection.
Cardinal words: Skin pathogens, Procedural and surgical site infection, Skin preparation solutions
Surgical site infection (SSI) complicates an estimated 5% of all make clean-contaminated operations performed annually in US hospitals and accounts for the virtually common nosocomial infection in surgical patients.1 Patients who develop SSI accept longer and costlier hospitalizations and are more probable to spend time in an intensive care unit (ICU), are v times more likely to be readmitted, and are twice every bit likely to die.two
Recognizing this substantial morbidity and economic burden, in 1999 the Centers for Disease Control (CDC) issued standardized guidelines for the prevention of surgical infections. These included making specific evidence-based recommendations for modifying patient factors that may predispose to infection, for the utilize of antimicrobial prophylaxis, for optimizing sterility in the operating room, and for the apply of clarified agents for skin grooming.
The choice of which specific amanuensis to employ for skin preparation was non addressed due to the diverseness of sites and approaches in surgery, as well every bit the absenteeism of data on SSI gamble in well-controlled, operation-specific studies.i Therefore, the choice of amanuensis should be based primarily on the surgeon's knowledge of the product'south efficacy, toll, and ease of use. Urologic surgeons have the boosted challenge of choosing the all-time amanuensis for the variety of procedures that they perform, including intraperitoneal and extraperitoneal surgery; scrotal, perineal, and vaginal operations; endoscopy; and percutaneous renal surgery. Each of these operative sites has different endogenous flora, torso contours, and pare types, all factors that influence the hazard of SSI and, therefore, the all-time type of antiseptic pare agent to use. This article focuses on skin preparation for the prevention of SSI with an assessment of currently available antiseptic products and their application to urologic surgery.
History
The offset use of an antiseptic pare agent in surgery is credited to the English surgeon Joseph Lister (1827–1912). Prior to the mid-19th century, limb amputation was associated with an alarming 50% postoperative mortality from sepsis. Following Louis Pasteur's discovery that tissue decay was acquired past microscopic organisms, Lister theorized that the spread of these microbes through surgical wounds was responsible for death in the postoperative flow. Lister began treating wounds with carbolic acid (phenol) in an effort to forbid tissue decay and the resultant infectious complications. Equally a result, the incidence of surgical sepsis savage dramatically, catalyzing the adoption of modern antiseptic techniques, including musical instrument sterilization, the use of surgical scrub and rubber gloves, and sterile patient preparation.iii
Modern Surgical Skin Preparation
The nearly common skin preparation agents used today include products containing iodophors or chlorhexidine gluconate (CHG). Agents are further classified by whether they are aqueous or alcohol-based solutions (Tabular array i).one
Table 1
Characteristics of Antiseptic Solutions
| Antiseptic | Machinery of Action | Antimicrobial Coverage | Onset | Duration | Awarding | Examples |
| Aqueous-iodophor | Free iodine − poly peptide, DNA damage | Excellent for gram + bacteria, skillful for gram −, fungi, virus, Mtb | Intermediate | 2 hoursnineteen | ii-footstep scrub and paint | Betadine* Scrub Intendance† |
| Aqueous-CHG | Disrupts membranes | Fantabulous for gram +, skilful for gram − and virus, fair for fungus, poor for Mtb | Intermediate | vi hourstwenty | 2-footstep scrub and dry, echo | Hibiclens‡ |
| Alcohol-iodophor | Denatures protein, gratis iodine − protein, DNA damage | Improved gram −, Mtb activity | Rapid | 48 hours (DuraPrep)xi 96 hours (Prevail-FX)21 | 1-step paint Dry time, minimum of iii min on hairless surface | DuraPrep solution§ Prevail-FX† |
| Alcohol-CHG | Denatures protein, disrupts membranes | Improved gram −, Mtb, fungal activity | Rapid | 48 hours22,23 | Dry out site: xxx-sec scrub Moist site: 2-min scrub Dry time, minimum of three min on hairless surface | ChloraPrep |
Aqueous-Based Solutions
Aqueous-based iodophors such as povidone-iodine (PVP-I) contain iodine complexed with a solubilizing amanuensis that allows for the release of free iodine when in solution. Iodine acts in an antiseptic style by destroying microbial proteins and Deoxyribonucleic acid. Iodophor-containing products enjoy widespread use because of their broad-spectrum antimicrobial properties, efficacy, and safety on nearly all pare surfaces in patients regardless of age. In the aqueous form, nearly commercially available iodophors require a two-step application in a scrub-and-paint technique, and their activity is express by the amount of time the agent is in contact with the pare.4 A 2nd product, aqueous-based chlorhexidine gluconate (CHG), works by disrupting bacterial prison cell membranes. CHG has more than sustained antimicrobial action and is more resistant to neutralization past claret products than the iodophors. CHG is applied in a similar way to PVP-I, but should not exist used in the genital region. This agent has gained popularity as a hand-scrubbing and showering antiseptic prior to surgery, but also continues to exist used as a patient skin preparation agent.v
Alcohol-Based Solutions
Ethyl and isopropyl alcohol are 2 of the most constructive antiseptic agents available. When used alone, booze is fast and short interim, has wide-spectrum antimicrobial activity, and is relatively inexpensive.one Booze-based solutions that contain CHG or iodophors have sustained and durable antimicrobial activity that lasts long after alcohol evaporation.six Because alcohol dries on exposed skin within moments of awarding, these can be applied with a i-step preparation as opposed to a scrub-and-paint technique.
A limitation to the use of alcohol in the operating room is its flammability on skin surfaces prior to evaporation. In that location accept been a few reports of operating room fires originating from alcohol-based skin preparation resulting in significant injury to patients and staff.seven Flammability can be avoided by assuasive skin to completely dry and avoiding preparation of areas with excessive trunk pilus that can filibuster alcohol vaporization.
Additionally, booze-based solutions should not be applied to mucous membranes and therefore have limited utility as antiseptic agents prior to transurethral or transvaginal surgery. Still, combination solutions with booze and CHG or iodophors take gained popularity among general, cardiac, and orthopedic surgeons and may have additional utility in certain urologic procedures. Recent studies suggest that these products may have greater efficacy, easier application, improved durability, and a superior cost profile when compared with traditional aqueous-based solutions.
One such product, 3M™ DuraPrep™ Surgical Solution (Iodine Povacrylex [0.vii% available iodine] and Isopropyl Alcohol, 74% west/w) Patient Preoperative Skin Training (3M Wellness Care, St. Paul, MN), is an clarified pare solution that contains iodine povacrylex and isopropyl alcohol. It is applied in 1 step, has a dry time of a minimum of 3 minutes on hairless skin, leaves a water-insoluble picture show on the skin surface that maintains antimicrobial activity for upwards to 48 hours, and resists wash-off past saline and blood products (Figure 1). In vitro studies have demonstrated that DuraPrep solution is effective confronting a wide range of microorganisms, including those virtually commonly encountered in genitourinary (GU) surgery, including gram-negative rods, Staphylococcus species, and Enterococcus, as well as multidrug-resistant organisms such equally methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and vancomycin-resistant enterococci (VRE).eight Furthermore, DuraPrep solution accomplishes a six-fold bacterial log reduction within one minute of contact with a greater percentage release of gratuitous iodine when compared with the leading aqueous iodophors.8
Application of DuraPrep™ Surgical Solution (3M Health Care, St. Paul, MN). Adapted with permission from 3M Health Care.
Another potential advantage of this production is its durability in the surgical environment. In a prospective, randomized surgical simulation study, DuraPrep solution demonstrated meliorate antimicrobial activeness later saline soak when compared with the leading CHG alcohol-based solution (ChloraPrep®; CareFusion, Inc., Leawood, KS), suggesting that it is particularly suitable for utilise in "wet" surgical environments (Figure 2).9 Some other unique characteristic of DuraPrep solution is that it enhances adhesion betwixt surgical drapes and the prepared skin surface, theoretically limiting the spread of organisms onto the surgical field. In a randomized, prospective report comparing drape adhesion in patients undergoing total joint replacement, patients prepared with DuraPrep solution had significantly less area of curtain elevator than those prepared with PVP-I, 1.5 cm2 versus nine.9 cm2, respectively (P < .0001).ten This agglutinative property may exist peculiarly advantageous for long, open procedures with the potential for fluid spillage on the surgical field, such equally cystoprostatectomy, radical prostatectomy, and retroperitoneal lymph node autopsy (RPLND).
Bacterial log reduction after saline challenge. *P < .003 for soak condition. Reproduced with permission from Stahl JB et al.9
Although there have been no studies in the urologic literature addressing the effect of this production on SSI, clinical studies take been conducted in general, cardiac, and orthopedic surgery, equally well equally in patients undergoing anesthesia procedures. In a prospective, randomized written report of full general surgery patients undergoing operations iii hours or longer, the apply of DuraPrep solution resulted in a 3-fold decrease in SSI when compared with tincture of iodine.11 Another study of 3209 general surgical procedures compared the utilise of iii skin preparations: a povidone-iodine scrub-paint combination (Betadine®, Purdue Products, LP, Stamford, CT) (with an isopropyl alcohol application between the steps), ChloraPrep, and DuraPrep solution.12 This study employed a sequential implementation design, and each agent was used for a 6-month period for all general surgery cases. PSSIs were tracked for 30 days.
DuraPrep solution was associated with the everyman infection rate (3.9%, compared with vi.4% for Betadine and seven.1% for ChloraPrep [P = .002]). In subgroup analysis, no difference in outcomes was seen betwixt patients prepared with Betadine/alcohol and those prepared with DuraPrep solution, simply patients in both these groups had significantly lower PSSI rates compared with patients prepared with ChloraPrep (iv.8% vs viii.two% [P = .001]).
In the cardiac literature, a comparing of DuraPrep solution with the leading PVP-I in patients at loftier adventure for SSI undergoing open up heart surgery, four of 101 patients in the DuraPrep solution group adult wound infections compared with 14 of 108 in the PVP-I group.13 At another eye, the introduction of DuraPrep solution in a cardiac surgery service was associated with a more than than l% reduction in overall SSI, sternal wound infection, and repeat surgical intervention for infection.14
In a study of patients undergoing epidural catheter placement on an obstetrics ward, DuraPrep solution was prospectively compared with PVP-I. The DuraPrep solution group showed a pregnant decrease in the number of positive skin cultures obtained immediately after disinfection and immediately prior to catheter removal. In add-on, bacteria was cultured from 2 epidural catheter tips in patients treated with DuraPrep solution compared with xiii positive cultures from catheter tips in the PVP-I group.15 This finding suggests that DuraPrep solution may exist especially suitable for percutaneous renal access procedures where catheters are frequently left in place postoperatively, thus serving every bit a potential entry point for infection.
Finally, a prospective clinical report in the orthopedic literature suggests that alcohol-based solutions with iodophor or CHG may have improved efficacy at reducing bacterial counts in "moist" surgical sites or body regions with increased endogenous bacterial colonization. One hundred 20-five patients undergoing human foot and ankle surgery were randomized to receive preparation with 3M™ DuraPrep™ Surgical Solution (Iodine Povacrylex [0.7% available iodine] and Isopropyl Alcohol, 74% w/w) Patient Preoperative Skin Grooming, ChloraPrep, or Techni-Care® Surgical Scrub (Care-Tech Laboratories, Inc., St. Louis, MO). The sites treated with alcohol-based solutions had on average a 50% reduction in positive cultures compared with those treated with traditional clarified agents. Overall, ChloraPrep performed 2-fold better than DuraPrep solution, but the findings of this written report take been criticized considering no neutralization agent was used prior to obtaining cultures from the surface of the treated areas. Because ChloraPrep is a not-moving picture forming clarified, without the use of a neutralizer, information technology is probable that in this grouping, sampling contaminated with clarified led to ongoing bacterial decease and exaggerated efficacy. Additionally, no patients developed SSI in the DuraPrep solution group.sixteen
These findings can be generalized to other "moist" surgical sites, suggesting that alcohol-based solutions may be efficacious for use in groin, scrotal, or perineal urologic surgery, especially for implantation of foreign devices such as penile prostheses or artificial urinary sphincters where minimizing bacterial counts is critical.
In improver to an analysis of efficacy, ease of utilise, price, and user satisfaction are important considerations when choosing a skin preparation agent. In a prospective comparison of booze-based iodophors with traditional PVP-I preparation, the alcohol-based solutions had shorter application and drying times. Taking into consideration operating room time and product expenses, the alcohol-containing products had lower overall costs.17 Other studies accept confirmed this finding, showing that the apply of DuraPrep solution has potential savings of $78 per patient (Table 2).eighteen Despite these advantages, operating room personnel preferred PVP-I scrub-and-pigment to the alcohol preparations, citing concern over flammability as the almost important overall deciding factor. Familiarity with PVP-I scrub-and-pigment, however, may have introduced bias into the assessment of user satisfaction because personnel had little to no feel with booze-based solutions prior to the written report.19 With prophylactic use and proper education, alcohol-based antiseptics may salvage valuable fourth dimension and operating room resources.
Table ii
Comparison of Antiseptic Products
| OR Immovability | Incidence of Surgical Site Infection | Ease of Use | |||||
| Antiseptic | Soak | Drape lift | General | General | Cardiac | Application | Price |
| Stahl et al9 North = 36 P = .006 | Jacobson et al10 N = 171 P < .0001 | Pinheiro et alxi Northward = 214 P < .05 | Swenson et al12 N = 3209* P < .002 | Segal and Anderson13 N = 209 P = .02 | Armstrong et al17 Due north = 25 | Roberts et al18 N = 200 P = .0001 | |
| DuraPrep solution† | three.7 bacterial log reduction | 1.five cmii | 4.8% | 3.9% | 4% | 82.8 sec With drape application | $56.96 |
| Tincture of iodine | – | – | fourteen.7% | – | – | – | |
| Prevail‡ | – | – | – | – | 42.2 sec | – | |
| ChloraPrep§ | 3.2 bacterial log reduction | – | – | 7.one% | – | – | – |
| PVP-I | – | 9.9 cm2 | – | 6.iv% | 13% | 228 sec | $135.28 |
Determination
The goal of preoperative skin preparation is to reduce the incidence of SSI in a safety, user-friendly, and toll-effective way. Because urologists perform a breadth of different operations accessing numerous surgical sites, a standard antiseptic agent is unlikely to be uniformly optimal. Traditional aqueous-based iodophors such as PVP-I are platonic for transvaginal and transurethral surgery and are ane of the few products that tin can be safely used on mucous membrane surfaces. Besides, alcoholbased solutions such every bit DuraPrep solution are quick, sustained, and durable with broader spectrum antimicrobial activity. These seem ideal for longer open surgeries with the potential for irrigation or surgical spillage, for percutaneous procedures with indwelling catheters, and for prosthesis implantation when minimizing pare colony counts is critical to prevent hardware infection. Considering alcohol is flammable, when using these products care must be taken to allow adequate drying time and to remove excessive pilus from the prepared field that may delay booze vaporization.
Footnotes
Dr. Micah 50. Hemani and Dr. Herbert Lepor accept been reimbursed by 3M Company for their contributions.
References
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809986/