Usual practices in surgical site preparation do not reduce infections

Antiseptic cleansing and body hair removal do not reduce surgical site infections, investigators report in two new reviews of studies of these common preoperative practices.

"Washing or showering with an antiseptic before going to surgery does not reduce the risk of developing a postoperative wound infection," said Joan Webster, lead author of the review on preoperative cleansing. "Therefore, patients may be advised to wash with any soap product; this is sufficient to remove transient flora [skin bacteria]."

Webster is associate professor and nursing director for the Research Center for Clinical Nursing at the Royal Brisbane and Women's Hospital in Herston, Australia.

The reviews appear in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Surgical site infections can occur after invasive surgeries. Antiseptic skin wash is commonly used during preoperative bathing or showering in order to reduce skin bacteria. But it has not been shown that this actually reduces rates of surgical site infections.

Likewise, removal of hair from an intended surgical wound site is routine, but its value for avoiding infections had not been conclusively demonstrated.

"The evidence finds no difference in surgical site infections among patients who have had hair removed prior to surgery and those who have not," concluded Judith Tanner and colleagues in the second review. "If it is necessary to remove hair then clipping results in fewer surgical site infections than shaving using a razor," they added.

Tanner is lead for nursing research at Derby City General Hospital in Derbyshire, England.

For both reviews, the investigators gathered and analyzed data from prior clinical trials meeting the rigorous standards of the selection process.

For the bathing and showering review, the reviewers found six eligible studies with 10,007 participants. The antiseptic used in all of the trials was four-percent chlorhexidine gluconate (Hibiscrub).

The authors found no difference in postoperative surgical site infection rate between patients who did and not wash with chlorhexidine, and add that the practice has a downside.

"Antiseptic-impregnated sponges, which are normally used for preoperative showering, are not inexpensive, so there are implications for cost savings to the health care industry," said Webster. "And because pathogenic organisms quickly become resistant to antiseptic solutions, it is important to limit the use of such solutions to situations where effect has been demonstrated," she said.

For the hair removal review, the authors found 11 eligible studies with 5775 participants. "Trials which compared hair removal with no hair removal prior to surgery, either using razors or a depilatory cream, demonstrated no statistically significant difference in surgical site infections between comparison groups," the authors reported.

Notably, three of the trials involving 3,193 subjects showed that patients who were shaved rather than clipped preoperatively had a statistically significantly higher rate of surgical site infections.

"The conclusion is that if hair removal is necessary at a surgical site, clipping is preferable," said William Schecter, M.D., professor of clinical surgery at the University of California at San Francisco. "There is no information available regarding the necessity to remove hair from a surgical site. I almost always remove hair at the site of a planned operation but there is little research to support or refute this practice," he said.

As for bathing or showering with an antiseptic, Schecter said, "It's hard to argue with a good shower prior to surgery in a patient who is either dirty or hasn't washed in some time. I work at San Francisco General Hospital" - he is chief of surgery - "and unfortunately, many of my patients are homeless so this is not an uncommon problem. However, there is no evidence that washing with skin antiseptics prevents surgical site infections."