Optimal Approaches to Skin Preparation Prior to Neurosurgery
increase with patient age, operation type (e.g. shunts), presence of foreign bodies, diabetes, and intracranial pressure monitoring.7
In a case series of 1,747 patients from a Milan hospital, Valentini et al. identified that surgical duration of greater than two hours and the patient’s age being in the 16–50 years range as being significant risk factors for infection.11
A similar French case series involving 7,399
patients identified the type of operation, operation modality, timing (higher risks with postponed operations), and duration of surgery as significant risk factors predisposing to SSI. They also noted a slight increase in risk with cerebrospinal fluid shunts.12
Cronquist et al. noted that obesity may play a pivotal role in neurosurgical SSI (relative risk 2.5) during a study attempting to correlate presurgical bacterial colonization density with infection risk.13 This case series also addressed the duration of surgery, noting an increase in risk with every additional 30 minutes and the patient’s age as factors.
Several studies looking at spine surgery alone have identified diabetes and pre-existing trauma as important negative predictive variables.6,14 Deep brain stimulation surgery has also been reported to have a 5.7% SSI (skin infection) rate, which was a major factor associated with prolonged hospital stays and the need for repeated surgery.15
In this article, the currently-available options for skin preparation prior to neurosurgery and their likely impact on reducing SSIs are explored.
Current Options for Pre-surgical Skin Preparation A variety of antiseptic agents are available for preparing skin prior to surgery. Options include alcohol (ethyl alcohol 60–90% or isopropyl alcohol 50–91%), chlorhexidine (with or without alcohol), iodophors (with or without alcohol), and para-chloro-meta-xylenol and trichlosan (used in surgical scrubs). An overview of the current recommended practices and most frequently used skin preparations are presented in Table 1 and detailed in the following sections.
It is important to remember that the performance of the currently available surgical antiseptics is variable. For example, aqueous iodophors (e.g. Betadine® skin cleanser) for scrubs/paint application have an immediate onset and last for approximately two hours.16 Alcohol-iodophors (e.g. DuraPrep) have a similar rapid onset and last for significantly longer (48–96 hours).17
direct skin preparation include antibiotic-impregnated drapes, the use of pre-operative antibiotic therapy, and good sterile technique.
The use of antibiotic-impregnated drapes has increased in recent years. In early studies, such drapes were not shown to reduce infection, but decreased overall bacterial count (iodine-impregnated drape versus paint alone or versus paint with non-impregnated drape).18
In one
notable study, the effect of an iodophor-impregnated plastic adhesive drape (Ioban) applied to operation sites 24 hours prior to orthopedic surgery was analyzed. The contamination of deep surgical wounds with bacteria shown to be present on the skin prior to disinfection and surgery was investigated. Bacterial sampling of the wounds after surgery showed that without the drapes there was a 15% rate of deep
US NEUROLOGY
Comparison between Iodine- and Clorhexidine-based Compounds
Both iodine-based and chlorhexidine-based preparations have specific properties that prevent infection. Aqueous-based iodophors, in particular povidone-iodine, allow for the release of free iodine when in a solution. Iodine is an elemental compound that works by destroying microbial proteins and DNA. These products are used widely because of their broad-spectrum antimicrobial action and their efficacy and safety on nearly all skin surfaces.
Alcohol is fast and short-acting. It also has broad-spectrum activity and is relatively inexpensive. Flammability can be an issue but can be avoided by allowing the skin to dry completely and avoiding the preparation of areas of the body with excessive body hair that can delay vaporization.
Alcohol-based solutions may have greater efficacy, easier application, improved durability, and a superior cost profile compared with traditional aqueous-based solutions.22
wound infection, but this was reduced to 1.6% when the drapes had been applied.19
In addition, pre-operative antibiotic therapies and good sterile techniques have always been recognized in literature as helpful in reducing the risk for SSIs.20,21
Iodine povacrylex in isopropyl
alcohol (DuraPrep) is one example of such a solution. It has the unique property of increased durability in the surgical and procedural environment because it enhances adhesion between the prepared skin surface and the surgical drapes. This is thought to limit the spread of organisms onto the surgical field.
In a 2009 prospective randomized trial, povidone-iodine and chlorhexidine were compared to study the efficacy of the reduction of bacterial colonization and subsequent surgical wound infection rates. Five hundred surgical patients were randomized to two separate groups, each receiving one of the two preparations. Bacterial colonization via cultures taken at the time of operation and resultant infection rates were utilized and the data analyzed. A significant reduction in the rates of bacterial colonization and subsequent infection in the chlorhexidine group compared with the povidone-iodine group was clearly demonstrated.23
Other important adjuncts to
A similar study performed in
a multihospital setting found comparable results. Pachareon et al. randomized 500 adults undergoing clean-contaminated surgery in six hospitals into two groups having their surgical sites prepared with either a chlorhexidine group (CHG)-alcohol solution or an iodophor-alcohol solution. The primary outcome was SSI within 30 days of surgery. The results demonstrated a significantly lower SSI rate in the CHG-alcohol group than in the povidone-iodine group.24
It was also noted that the
CHG-alcohol preparation was significantly more protective against superficial/deep skin infections, but not against organ-space infections. However, the results of more recent studies suggest the opposite effect. One notable but non-randomized, study was performed by Swenson et al. at a single center. Over 3,000 general surgery patients received three different skin preparations during three sequential six-month periods. These preparations included:
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