Preoperative skin preparation with povidone-iodine

Preoperative Skin Preparation Povidone-Iodine

with

A. STEPHEN CLOSE, M.D.,BRUCE F. STENGEL, M.D., HARRY H. LOVE, M.D., MARIE L. KOCH, AND MILES B. SMITH, M.D.,Milwaukee, Wisconsin

From tbe Surgical Service, Wood Veterans Aclministration Hospital, and tbe Division of Surgery, Marquette University School of Medicine, Milwaukee, Wisconsin.

gram-positive or gram-negative bacteria after fifteen seconds contact [I]. To satisfy the psychoIogic needs of surgeons and nurses for the appearance of suds during scrubbing and to provide better mechanica cIeansing, we eIected to evaIuate Betadine SurgicaI Scrub which contains povidoneiodine and a detergent. We compared the incidence of skin reactions, wound infections and pre- and postscrubbing skin sterility over a period of two years, utiIizing either hexachIorophene soap or Betadine. As a resuIt of this study Betadine SurgicaI Scrub has been our principa1 operating room skin-degerming agent for nearIy four years, and this report wiI1 present our experience with this agent, particuIarIy during the two year period of study.

URING recent years hexachIorophene-containing soaps and detergents have enjoyed widespread use as preoperative degerming agents despite the fact that such agents seIdom steriIize skin. Random cuItures of surgeons’ skin in our hospita1 Ied hands and patients’ to the conviction that a hexachIorophene soap* foIIowed by aqueous Zephiran@ chIoride (I :1,000)often Ieft a great many viable bacteria on the skin, and that even more bacteria couId be cuItured at the concIusion of the operative procedure. For this reason interest in degerming agents which would act rapidIy to destroy most or a11 skin bacteria and maintain bactericida1 activity during surgery was stimuIated. Iodine has been known to be a very fastacting potent broad-spectrum bactericida1 agent for many years, and its recent appearance in organic form warrants reappraisa1 of its potentia1 as a preoperative skin-preparing agent. ActuaI burning of the skin and other sensitivity reactions were formerIy of such frequency that iodine has been used IittIe during the past twenty years; however, these reactions are apparentIy rare with the newer organic compounds which reIease iodine steadiIy and do not need aIcoho1 as a vehicIe. Betadine@? is a commerciaIIy avaiIabIe organic iodine compIex (haIogenated poIyvinyIpyrroIidone) containing I per cent free iodine, which even when diIuted ten times kiIIs most

D

METHOD Two preoperative skin preparations were compared during aIternate months over a two year period, (I) Patient’s skin. When shaving of operative sites was indicated, the patients were shaved immediateIy prior to operation. The skin of the operative area was scrubbed for five minutes with sponges dipped in pHisoHex,@ the pHisoHex was removed with dry sponges, and the skin was scrubbed gentIy with large quantities of aqueous Zephiran. With the aIternate method the skin was scrubbed simiIarIy with Betadine SurgicaI Scrub, which was then removed with dry sponges. Aqueous Betadine was then applied and aIIowed to dry. (2) Surgical team. Hands were scrubbed for seven minutes with hexachIorophene soap (Septisol). With the alternate method Betadine Surgical Scrub was used, and foIIowed by a spray of aqueous Betadine. Scrubbing technic was not supervised and no specia1 instructions were given. On the first day of each month the contents of a11 operating room dispensers were changed from one agent to the alternate untiI twenty-four months’ experience was accumuIated. During this

* Septisol, VestaI Co., St. Louis, Missouri. t Betadine and Betadine Surgical Scrub were suppIied by Physicians Products Co., Inc., Petersburg, Virginia. American

Journal

of

Surgery,

Volume

108, Septembe+

1964

PH.D.

398

Skin

Preparation

lvith I%\-idone-IotI1 ne In the po\-idone-;otl;ne there were twenty-one wound infections, an incidence of I .g per cent. Although the incidence of wound infection LI’X lower with povidone-iodine, the difference is not statisticalIy significant. Skin Reactions. During the first two years of the study, four different members of surgical teams reported dermatitis occurring during hcxachlorophene-Zephiran months which subsided with a change to povidone-iodine. One surgeon reported dermatitis during a povicIoneiodine month which persisted during periods of frequent scrubbing, but subsided when he operated only a few times per week. This difference in the incidence of dermatitis is not statisticaljy significant; however, the very low incidence of reaction to the organic iodine certainly does attest to its superiority over nonorganic iodine, and verifies that rt can be safely used continuously by the surgical team. Staining of the skin was not noted with the povidone-iodine preparation. No major skin reactions were reported in any patient in either of the groups as far as the operative sites were concerned. However, in many Iower abdominal operations, minor asymptomatic edema and injection of the scrotum followed by desquamation was noted after hexachIorophene-Zephiran preparations, and was rarely seen with povidone-iodine. This was so frequent in the experience of the surgeons prior to the study that they did not report such cases and we have no figures to present. During the subsequent two years of povidone-iodine use, this desquamation has seIdom been seen. The results of the finger tip cultures are shown graphically in Figures I and 2. With hexachIorophene and Zephiran, the finger tips demonstrated surface steriIity in only 21 per cent of the forty-two cuItures taken right after scrubbing in contrast to the povidoneiodine (PVP-I) group in which 97 per cent of the thirty-four cuItures were sterile (one pIate grew one coIony). Postoperatively, a significant difference was again noted (p = < .025) ; 66 per cent of the personnel stiI1 had sterile finger tips when they scrubbed with povidone-iodine compared with onIy 18 per cent when they scrubbed with hexachIorophene. Additiona evidence of the inferiority of the hexachIorophene scrub is seen in Figure 3 which points out that in those cuItures which were positive, a great many more coIonies

period each surgeon, IlLlI'SC and student \vas requested to JC~OJO any incidence of skin sensitivity in t hemselvcs or their patients. In addition, the record of each patient was rcviewcd and his physician inter\ iewcd at the time of discharge so that \\ound infections and skin I-cactions could bc accurately I-ccordcd. Patients from the general surgical, thoracic, vascular, orthopedic and neurosurgical services were included, hut all patients undergoing open-ative procedures with known or highly probable contamination from sources other than skin were excIuded, that is, coIonic resection, emergency gastrectomy, smaI1 bowel obstruction Lvith resection, noneIective appendectomy, drainage of abscess, skin grafts and the like. After two years of study, there were 1,103 patients in the hexachlorophcne-Zephiran group, and I, 10s patients in the povidone-iodine group. Since infection rate couId be expected to be low in such a group of clean cases, it seemed doubtful that statistically significant resuIts would be achieved in two years, especially when one considers that skin preparation may be one of the Iesser factors in infection of clean operative wounds. For this reason we wiI1 base our concIusions primarily on the results of the foIlowing part of the study. The aIternate scrubbing agents and methods just. described were further evaIuated by cultures finger tips and the patients’ of the surgeons’ umbilicus. Patient’s Skin. A damp swab was rotated several times in the umbiIicus immediateIy after skin preparation and again after the operation was compIeted. The swabs were placed in broth and incubated at 37’~. for twenty-four hours. Pour plates in trypticase-soy agar were made and again incubated twenty-four hours after which colony counts were tabulated. When the skin was prepared with Betadine, the culture media contained 0.2 per cent sodium thiosulfate for neutralization of any iodine which might be carried over into the media. When pHisoHex was used, the cuIture media contained 0.5 per cent Tween’” 80 and 0.1 per cent yeast extract for neutralization. Surgical Team. On unannounced days surgeons \vere requested to indent blood agar plates with all five finger tips of the right hand. If five fingerprints were not visible in the agar, the plate was discarded. These finger tip cuItures were obtained from dry hands just before the surgeon donned gloves prior to operation and again after concIusion of the operative procedure. RESULTS

Infection Rate. There were 1,105 patients in the hexachlorophene-Zephiran group, and twenty-six wound infections occurred, an inci-

399

dcncc

of 2.4 per cent.

group

of I, 103 patients,

CIose et a1. 38’

32

%

Tot01 Cultures

Ster$e

TofOl

studies

Culfwes

of surgeons

and

l includes

1st assistants

were seen with hexachIorophene (mean of seventy-five per pIate compared with thirteen in the postoperative cuItures after povidoneiodine scrubbing). SimiIar significant differences were noted in the umbiIicus cuItures which were steriIe twice as often with povidone-iodine and averaged fifty times as many coIonies in positive cuItures from hexachIorophene-Zephiran prepared patients. One additiona interesting observation was made; that is, in the povidone-iodine group of finger tip cuItures, there were five instances of glove changes during operation because of perforations. In a11 five instances organisms were cuItured in the postoperative fingerprint pIates. In the group without gIove changes 0nIy six of twenty-seven fingerprint pIates grew organisms.

Hemchhvophme

ond

Powdone

- lo&he

1st essisfannt

Iodine has Iong been known as a powerfu1 germicide; however, inorganic iodine burns mammaIian ceIIs and is very irritating in its most effective form, the tincture. The recent advent of organic chemicaIs which reIease iodine sIowIy has prompted re-evaIuation of iodine as a skin antiseptic. Povidone-iodine kiIIs micrococcus aureus in ten minutes at onesixteenth the concentration required for 3 per cent hexachIorophene soap (pHisoHex) and at one-fourth the concentration required for Zephiran chIoride [2]. Zephiran chIoride may not be bactericida1 in the aqueous diIution usuaIIy used for the brief contact common after surgica1 skin preparation, and in fact was once incriminated as a source of hospita1 infection [?I. Other evidence of the unreIiabiIity and overestimated antibacteria activity of hexachlorophene and Zephiran chIoride has been given by ZinteI [4] and EIIison [5]. In a study simiIar to ours, Joress has shown the marked superiority of povidone-iodine as a surgica1 antiseptic [6]. With carefuIIy controIIed scrubbing methods, even better skin preparation was accompIished in his studies of voIunteers and patients than in ours. No attempt was made to reguIate or contro1 scrubbing procedures in our study so that we couId obtain resuIts which shouId represent those one couId expect from everyday use in any operating room. Our umbiIica1 cuItures grew far more organisms with hexachIorophene soap and Zephiran, but are more representative

PVP-I

b Preopmtive fp=COOsl

of surgeon

COMMENTS

25

&

studies

FIG. 2. The difference between postoperative skin surface steriIity with hexachIorophene and Betadine is significant (P = <.025).

FIG. I. The difference between preoperative skin surface steriIity with hexachlorophene and Betadine is significant (P = <.oos).

Count

Culfures

Soap

Hexochloqhwe

hvidone-Iodine

tkmchloropheneSmp

l includes

Sterile

Sterile

Culfures

Postoperative /p = <.005J

FIG. 3. Hexachlorophene soap versus povidone-iodine. CoIony count of finger tip cuItures.

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Skin

Preparation

with

of’ the difficulty cleansing the umbilicus than of the germicidal activity of the chemical agents tested. Joress obtained patient skin surface sterilization in thirty-nine of forty patients scrubbed with Betadine SurgicaI Scrub which is the same result we obtained in hand prepara.tion of the surgical team. During the past two years of routine use of Betadine SurgicaI Scrub, four nurses and one medical student have found that frequent use over proIonged periods caused some drying and erythema of the skin of their hands. Since they are able to use aqueous Betadine after scrubbing without such diffrcuIty, it is apparent that these are not instances of iodine sensitivity. CONCLUSION

AND

Po\.idone-Iodine will usuaIIy remain steriIe or harbor vc:ry t’e~ organisms at the conclusion of the operative procedure. Skin reactions associated with the use of Betadine Surgical Scrub are very rare in patients and infrequent in operating room staffs. Skin reactions are even Iess ConlnlOn wit,h aqueous Betadine. Neither agent causes staining of the skin even after prolonged use. REFERENCES

L. Povidone-iodine as a topical antiseptic. Am. J. Surg., 94: 938, 1957. GREENBERG, I.. Comparative laboratory evaluation of antiseborrheic dermatitis preparations. J. Pbarmaceut. SC., so: 480, 1961. _ _ MALIZIA, W. F., GANGAROSA,E. J. and GOLEY, A. F. Benzalkonium chIoride as a source of infection. New Eneland J. Med.. 26s: 800. 1960. ZINTEL, H’: A. Asepsis and antisepsis. S. Clin. Nortb America, 36: 257, 1956. ELLISON, E. H. Current thinking on hand scrubs and skin preps. OR Nursing, I: 46, 1960. .JORESS. , S. M. A studv of disinfection of the skin: a comparison of povidone-iodine with other agents used for surgicaI scrubs. Ann. Surg., 155: 296, 1962.

I. GEKSHENFELD,

2.

1.

SUMMARY

4.

Joress’ study of modern antiseptic agents concIusiveIy demonstrates that it is possibIe to steriIize the skin surface of surgeon and patient, and our study indicates that this can be accomplished with the ordinary scrubbing technics in genera1 use. Furthermore, the skin

6. 6.

401