Landmark NEJM study - SSIs cut by 41%
Released on - 29/01/2010
Landmark NEJM study - SSIs cut by 41% by switching prop skin prep
Volume 362:18 January 7, 2010 Number 1
Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis
Rabih O. Darouiche, M.D., Matthew J. Wall, Jr., M.D., Kamal M.F. Itani, M.D., Mary F. Otterson, M.D., Alexandra L. Webb, M.D., Matthew M. Carrick, M.D., Harold J. Miller, M.D., Samir S. Awad, M.D., Cynthia T. Crosby, B.S., Michael C. Mosier, Ph.D., Atef AlSharif, M.D., and David H. Berger, M.D.
The above study published in the NEJM (http://content.nejm.org/cgi/content/abstract/362/1/18) shows that use of Chlorhexidine–Alcohol instead of Povidone–Iodine for Surgical-Site Antisepsis cut infection rates by 41%. Currently, the vast majority of UK hospitals use Povidone-Iodine for preop skin antisepsis. Specifically, significant reductions were observed in both superficial (52%, P=0.008) and deep incisional infections (67%, P=0.05), more than halving the rate of SSIs compared to povidone-iodine. The abstract is below and a press release is attached.
Professor David Leaper said of the results: “These are compelling findings and should prompt a rethink on how hospitals prepare patients for surgery. Iodine is still widely used in hospitals, but this study demonstrates that switching skin antiseptic solution could dramatically cut surgical infection rates in the UK, preventing serious illness, saving lives and reducing a major cost burden on the NHS.”
In the UK, SSIs are among the most serious and costly hospital infections [i], affecting 1 in 20 patients who undergo surgery. Infected patients are twice as likely to die following surgery,[ii] stay at least twice as long in hospital[iii] and cost almost three times more to treat than uninfected patients.[iv] In the UK each year, more than 460,000 surgical procedures are estimated to result in wound infection,[v] with MRSA (Meticillin-resistant Staphylococcus aureus) accounting for a particularly high proportion. In fact, over 25% of SSI'S reported to the Health Protection Agency since 2004 were caused by MRSA,[vi] representing a significant burden of infection for hospitals.
ChloraPrep® (2 percent chlorhexidine gluconate and 70 percentalcohol) provides both rapid action[vii] against microorganisms and keeps fighting bacterial growth for at least 48 hours after application,[viii],[ix] whereas iodine is neutralized by blood and other organic matter, reducing its effectiveness to two hours.[x] The residual effect of ChloraPrep® allows for added protection for patients against infections after surgery, not just during the procedure. ChloraPrep® can reduce the number of bacteria counted on patients’ skin by 99.9%.[xi] Its efficacy not only lies in the superior antiseptic solution but in the way that it is applied, using a specially designed sterile applicator..It has already been widely adopted by the NHS with great success for use in peripheral and central intravenous lines – procedures involving over 30% of UK patients at any given time.[xii]
Southampton University Hospitals NHS Trust saw a 70% reduction in MRSA bacteraemia - from 92 cases in 2005/06 down to 27 in 2008/09 - after introducing ChloraPrep® as part of a package of infection control measures. Barking and Havering NHS Trust saw cases of MRSA infections from peripheral intravenous lines fall steadily from 13 cases in early 2007 to 0 cases by May 2009, also after introducing ChloraPrep® as part of a package of infection control measures. The National Blood and Transfusion service found the single use applicator, applied correctly, led to a 10-fold improvement in skin decontamination prior to donation.[xiii] It is now used routinely for all donations in the UK. “This study further underscores the product’s potential to prevent unnecessary infections for patients, free up hospital beds and cut costs for hospitals,” continued Professor Leaper. The efficacy and safety of ChloraPrep® for skin antisepsis prior to invasive procedures is supported by more than 35 clinical studies and recommendations across 17 internationally recognized organizations or guidelines, including 10 that specifically recommend 2% chlorhexidine – a key ingredient in ChloraPrep®.
[i] NICE 2008, Prevention and Treatment of Surgical Site Infection, October 2008
[ii] Kirkland KB et al. The impact of surgical site infections in the 1990s: attributable mortality, excess length of hospitalization and extra costs. Infection Control and Hospital Epidemiology, 1999;20:725-730.
[iii] Coello R, Charlett A, Wilson J, Ward V, Pearson A, Boriello P. Adverse impact of surgical site infections in English hospitals J. Hosp. Infect 2005; 60: 93-103
[iv] Public Health Laboratory Service. Socio-economic Burden of Hospital Acquired Infection. 1999
[v] Based on 9.27m surgical procedures in 2008 (www.hesonline.nhs.uk)and an infection rate of 5% (NICE 2008, Prevention and Treatment of Surgical Site Infection, October 2008)
[vi] Health Protection Agency, Healthcare Associated Infections in England. 2008-2009 Report.
[vii] Crosby CT , Mares AK. Skin antisepsis: past, present, and future. J Vasc Access Devices. Spring 2001:26-31.
[viii] Garcia R, Mulberry G, Brady A, Hibbard JS. Comparison of ChloraPrep and Betadine as preoperative skin preparation antiseptics. Poster presented at: 40th Annual Meeting of the Infectious Disease Society of America; October 25, 2002.
[ix] Data on file. CareFusion.
[x] Crosby CT , Mares AK. Skin antisepsis: past, present, and future. J Vasc Access Devices. Spring 2001:26-31.
[xi] Mcdonald CP et al.Evaluation and Routine Performance of a “best practice” donor arm disinfection procedure; chloraprep; p150. VoxSsanguins 2006; 94 (Supl.3)
[xii] Reilly J, Stewart S, Allardice G, et al. NHS Scotland National HAI Prevalence Survey. Glasgow: Health Protection Scotland; 2007. p. 81.
[xiii] Mcdonald CP et al.Evaluation and Routine Performance of a “best practice” donor arm disinfection procedure; chloraprep; p150. VoxSsanguins 2006; 94 (Supl.3)
