Evidence-based guidelines for chlorhexidine gluconate in preoperative skin preparation to reduce surgical site infection in patients undergoing general surgery

Abstract

Surgical site infection not only brings morbidity and mortality to patients, but it also bring substantial financial burden to the hospital and the healthcare system. To minimize the clinical consequences of surgical site infection, it is crucial that all appropriate measures for reduction of surgical site infection should be implemented. Since patient’s skin is a potential source of pathogens, normal skin flora is a common cause of surgical site infections. Preoperative skin disinfection of the surgical site with an antiseptic agent is an effective method to remove the soil and transient organisms from the skin. Currently, there are different skin antiseptics available and the most commonly used agents are povidone iodine and chlorhexidine gluconate. Although povidone iodine has a long-standing recommendation and it is widely used in various surgical procedures, it has several limitations. On the other hand, there is an increasing interest of the use of chlorhexidine in indwelling catheter placement and care, surgical hand scrubbing, as well as wound dressing.

In view of this, there is a potential of replacing povidone iodine by chlorhexidine as preoperative skin antiseptic agent. As there is no existing guideline supportingthis innovative movement, this dissertation aimed to review the currently available evidence on preoperative skin preparation and to develop an evidence-based guideline of using chlorhexidine in preoperative skin preparation for reducing surgical site infection in patients undergoing general surgery.

Five randomized controlled studies were identified from MEDLINE, CINAHL and PUBMED and evaluated by a critical appraisal tool, the Scottish Intercollegiate Guidelines Network. All studies reported that preoperative skin preparation with chlorhexidine is more effective than the use of povidone iodine in reducing surgical site infection. An evidence-based guideline is developed according to the guideline development process from the Scottish Intercollegiate Guideline Network. Patient characteristics, local clinical setting, organizational infrastructure and staff competency is congruent with the proposed innovation. The new protocol not only can minimize the risk of postoperative surgical site infection but also save costs. The cost-benefit analysis showed that the new protocol can help to save $675,552 to $1,097,772 (HK dollars) in six-month period after implementation.

To facilitate a more comprehensive plan in actual implementation of the proposed guideline, stakeholders at administrative, managerial, and operational levels would be invited to take part in the 12-week pilot test. Surgical site infection, staff satisfaction and compliance, as well as cost and benefit ratio of the guideline would be measured in the evaluation plan. The refined guidelines would then be implemented for one year. The effectiveness of the guideline would be determined by reduction in postoperative surgical site infection, increase in staff knowledge and satisfaction, and the overall expenditure.