Chlorhexidine Patient Bathing Prior to Arthroplasty

Evidence supports preoperative use of alcohol and/or chlorhexidine scrubbing of surgical sites¹ or hospital staff hands^2,3 to reduce the incidence of surgical site infections (SSIs) during the 30 days after surgery. Similarly, in-hospital patient bathing with no-rinse 2% chlorhexidine wash cloths reduced hospital-acquired infections⁴ or bacteremia⁵  in patients undergoing intensive care. However, contradictory results in the literature have generated confusion about the SSI preventive effects of patient showering or bathing with antimicrobial compounds 24 to 48 hours before surgery. One nonblinded randomized controlled trial (RCT) enrolling patients undergoing elective hernia, biliary tract, or cancer surgery⁶ reported fewer SSIs before hospital discharge (P < .05) for patients who bathed with 4% chlorhexidine gluconate (4% CHG; n = 541) compared with no bathing (n = 437) and fewer SSIs in those who washed their full body with 4% CHG (n = 541) as compared with the 522 who only washed part of their body with 4% CHG (P = .018). A 2015 update of a Cochrane meta-analysis unadjusted for SSI risk factors⁷ summarized 7 RCTs on 10 157 patients who bathed or showered using 4% CHG, preoperatively. The authors⁷ found a nonsignificant reduction in SSIs: 9.1% developed SSIs in the preoperative 4% CHG showering or bathing group compared with 10% for those who showered with the placebo (P = .17). A different systematic review and meta-analysis of 5 RCTs and 1 prospective observational study on 22 345 patients preparing to undergo clean contaminated surgery⁸ reported 5.7% SSIs in those who bathed with chlorhexidine compared with 7.9% SSIs in those whose skin was cleansed with povidone iodine (P = .019). None of these studies reported effects of preoperative antibacterial bathing on arthroplasty, which has a recognized risk for SSIs. Two recent contributions to the literature reviewed herein clarify the effects of chlorhexidine patient bathing prior to arthroplasty. One is a meta-analysis of studies on patients undergoing total knee arthroplasty (TKA)⁹; the other explores the effects of preoperative chlorhexidine bathing on patients undergoing knee or hip arthroplasty.¹⁰

Reference: Kapadia BH, Elmallah RK, Mont MA. A randomized, clinical trial of preadmission chlorhexidine skin preparation for lower extremity total joint arthroplasty [published online ahead of print May 31, 2016]. J Arthroplasty. 2016;31(12):2856–2861.

Rationale: Those who undergo total joint arthroplasty can experience renewed vigor and quality of life, but associated SSIs can be devastating.

Objective: The authors conducted a prospective, single-center, blind RCT exploring the effects of arthroplasty patient preoperative bathing with 2% chlorhexidine-impregnated no-rinse wash cloths compared with standard of care antibacterial soap and water bathing.

Methods: Patients undergoing primary or revisional TKA or hip arthroplasty in a US tertiary care hospital from March 1 through November 30, 2012, were randomly assigned to receive preadmission full-body washing with either no-rinse 2% chlorhexidine wash cloths or standard of care full-body washing using antibacterial soap. Each patient receiving the chlorhexidine wash received 2 packets of 6 no-rinse wash cloths: 1 packet to wash all body parts the evening before surgery and the other for all body parts on the morning of surgery, either self-administered or by hospital staff. These patients were told not to shower or rinse off the cleanser or apply any skin lotion or powder at any time after the first chlorhexidine full-body wash. Those assigned to standard of care bathed with antibiotic soap the night before surgery. All other aspects of standard of care were identical for the 2 groups. All pre-, peri-, and postoperative infection control procedures were performed as per the US Centers for Disease Control and Prevention (CDC) protocols for SSI prevention, including prophylactic 1 g cefazolin started 1 hour prior to surgery and a preoperative surgical site scrub and paint with alcohol and skin preparation with an iodine povacrylex and isopropyl alcohol solution. The primary endpoint was deep SSI incidence within 1 year following surgery. Superficial skin and subcutaneous tissue SSIs were documented but not included in the primary endpoint. Secondary endpoints were correlations of SSIs with the National Healthcare Safety Network (NHSN) infection risk scores from 0 (no risk) to 3 (high risk) based on recognized risk factors, including duration of surgery, smoking, American Society of Anesthesiologists (ASA) grade, and CDC wound classification as “clean” or “clean contaminated.” Only those who adhered to the assigned bathing protocol and completed the entire trial were analyzed.

Results: The treatment (n = 272) and control groups (n = 267) were comparable at baseline on all risk factors and NHSN infection risk scores. By the 1-year follow-up visit, there was 1 deep SSI in the 2% chlorhexidine group (0.4%) and 9 deep SSIs (2.9%) in the control (P = .038) and 1 superficial SSI in the chlorhexidine group (0.04%) compared with 5 (2.5%) in the control (P = .049). One patient in the chlorhexidine group experienced an adverse event (red wheals, which resolved within 2 days with local wound care). A study limitation was its early termination by the institution’s infection control officer who felt that it was no longer ethical to continue exposing the control patients to a higher risk of SSIs.

Authors’ Conclusions: Preoperative patient bathing with the 2% chlorhexidine wash cloths reduced the likelihood of deep and superficial SSIs following TKA or total hip arthroplasty.

Reference: Wang Z, Zheng J, Zhao Y, Xiang Y, Chen X, Zhao F, Jin Y. Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty: a meta-analysis. Medicine (Baltimore). 2017;96(47):e8321.

Rationale: Those undergoing TKA experience a 1% to 2% incidence of SSI. Effects of chlorhexidine preoperative bathing on TKA infection rates have been debated.

Objective: A systematic review and meta-analysis explored the effects of preoperative patient bathing before TKA surgery on postoperative SSI incidence.

Methods: The Cochrane Central Register of Controlled Trials, Web of Science, Google, EMBASE, and PubMed databases were searched from inception through February 2017 for RCTs or retrospective comparative studies in which patients undergoing primary TKA or TKA revision bathed preoperatively with any chlorhexidine formulation and compared to similar patients who did not bathe preoperatively with chlorhexidine. Searches and meta-analyses were conducted on SSI and total infection outcomes stratified by NHSN risk category. All searches and meta-analyses were conducted by 2 independent reviewers in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, using P < .05 for statistical significance. Evidence was evaluated using GRADEpro GDT software (McMaster University, Hamilton, Ontario, Canada), and search results were reported as per principles of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist.

Results: One RCT and 3 retrospective comparative studies of clinical databases on 8777 patients were included in the meta-analysis. Overall, preoperative chlorhexidine bathing reduced the incidence of SSIs by 1.69%, with a 0.22 relative risk (RR) of developing a SSI (95% confidence interval [CI], 0.12–0.40; P < .001) compared with nonchlorhexidine use. This reduction in risk of developing a SSI was not consistent for the 2606 low-risk patients (RR, 0.52; P = .33) but was statistically significant among the 2985 patients at a moderate risk of developing a SSI (RR, 0.18; 95% CI, 0.05–0.63; P = .007) and among the 1186 patients at a high risk of developing a SSI (RR, 0.13; 95% CI, 0.03–0.67; P = .014).

Authors’ Conclusions: The low quality evidence reviewed supports a significant effect of chlorhexidine preoperative bathing in reducing the incidence of SSIs in patients undergoing TKA who bear a moderate or high risk of developing a SSI. Good quality RCTs are recommended, with analyses adjusted for patient risk of developing a SSI.

The studies reviewed here offer growing evidence supporting reduced SSI risk resulting from whole body antimicrobial bathing on the day prior to a patient undergoing arthroplasty. We may not know the best antibiotic, vehicle, or dosage to optimize the intervention’s efficacy, safety and cost effectiveness, but these studies^9,10 have identified important parameters to control and risk factors that merit adjustment in meta-analyses examining this effect. Even though the study by Kapadia et al¹⁰ was discontinued early, the intervention’s capacity to reduce SSI risk was sufficiently robust for statistical significance. As Wang et al⁹ noted, their meta-analysis may have been biased by the small number of studies and inclusion of retrospective data that may have been biased by physicians’ choice of which patients received or did not receive preoperative chlorhexidine bathing. Also noted, there is a need for high-quality blind-evaluated RCTs to confirm that preoperative bathing with an antimicrobial skin cleanser can limit the likelihood of periprosthesis SSI after arthroplasty.

These results suggest that any future study of antimicrobial preoperative bathing procedure effects on reducing SSI risk should include analyses adjusting for a valid measure of patient SSI risk while encouraging and monitoring whole body bathing protocol adherence. The SSI rates should be consistently monitored daily during hospitalization and at least once weekly post hospital discharge. Well-designed trials should include risk-adjusted analyses for clean, clean-contaminated, contaminated, and dirty wounds as well as for SSI depth — ie, superficial, deep, or organ-space SSI, as described by the CDC. Evidence could improve on the optimal surveillance duration for arthroplasty-related SSI extending at least 30 days and optionally to 1-year postoperatively. Please be aware that the antimicrobial concentrations of the skin cleansers described in these studies are not intended for intraoperative or wound use and may interact with wound cleansing solutions¹¹ or harm eyes.¹²