Maximizing Skin Antisepsis in the Challenging Bariatric Patient

| December 17, 2009

by Charles E. Edmiston, Jr., PhD, SM (ASCP), CIC (CBIC)

Dr. Charles Edmiston is Professor of Surgery and Hospital Epidemiologist at Froedtert Hospital/Medical College of Wisconsin in Milwaukee, Wisconsin; Director of the Surgical Microbiology Research Laboratory in the Department of Surgery, and fellow of the Infectious Disease Society of American, Surgical Infection Society, and the Society for Healthcare Epidemiology of America

Bariatric Times. 2009;6(12):20–22

Reducing the risk of surgical site infection in the bariatric patient population requires a thoughtful evidence-based approach. An important component of this strategy is to reducing the microbial burden on the skin prior to surgical incision, which can be accomplished using “a step-wise” layer process involving a chlorhexidine gluconate formulation for both preadmission and perioperative skin antisepsis.

As healthcare practitioners providing care for bariatric patients, we are acutely aware that surgical procedures present a unique set of clinical considerations in this patient population. For any patient, it is important to minimize the risk of healthcare-associated infection (HAI) to avoid increased hospital length of stay and costs for additional care. Significantly increased risk of morbidity in the bariatric population means that clinicians should take extra care to avoid infections in these patients, which could send them to the intensive care unit (ICU), resulting in poor clinical outcomes.

Standard Approaches to Infection Prevention
Two key approaches to preventing infections include appropriate antimicrobial prophylaxis and implementation of a glucose control regimen. The goal of antibiotic administration should be to achieve maximal tissue concentration at the time of incision, which last throughout the surgical procedure. Obesity can complicate these efforts, however, as this condition is associated with alterations in fluid volume distribution and total body clearance.Specifically, antimicrobial tissue concentrations may be suboptimal at the time of surgery due in part to body composition, regional blood flow, affinity of the prophylactic agent for plasma proteins, and drug distribution within selected tissue compartments.[1]

In terms of glucose control, it has become widely accepted that surgical patients with blood glucose levels greater than 150mg/dL elevated blood sugars are at increased risk of infection following surgery.[2] Therefore, glycemic control protocols have been implemented, especially during the preadmission and perioperative period as an interventional strategy to improve patient outcomes. In the bariatric patient population, practitioners often embrace tight glucose control regimens since glucose normalization in many patients may be resistant to the standard glycemic protocols.[3] It should be noted, however, that universal acceptance of tight perioperative glucose control as a pathway to reduce morbidity and mortality in the surgical patient has come under recent challenge. Several independent investigators have suggested that implementation of an intensive insulin regimen may not significantly decrease patient morbidity but in fact may elevate the risk of hypoglycemia, increasing mortality in surgical and critically ill patient populations.[4–6] It is important to realize that there are no “silver bullets” for reducing the risk of surgical site infections, and the path to improved patient outcomes rarely follows a straight line.

Maximizing Skin Antisepsis: A Step-Wise Strategy
While antibiotic prophylaxis and other measures such as glycemic control are important in reducing the risk of infection, it is still vital to adhere to proper skin preparation practices in order to reduce the microbial burden on the patient’s skin prior to surgery. It is especially challenging to maximize skin antisepsis in this patient population because the physiology of their skin presents technical difficulties and increased potential for skin-dwelling micro-organisms, which may play a role in postoperative surgical site infection. Redundant skin folds in the bariatric patient create overlap and crevices, such as on the stomach, chest, or groin areas, making it difficult to achieve maximum skin antisepsis. In addition, routine activities tend to be labor-intensive in heavier patients, who tend to sweat profusely, producing excessive oily secretions on the skin, which in turn provides an excellent substrate for bacterial growth.
Because of these challenging conditions in the patient with high body mass index (BMI), a step-wise approach to maintaining maximal antiseptic activity is highly recommended for the bariatric patient. The approach involves a “layered antiseptic strategy,” in which the skin is exposed to an appropriate antiseptic challenge prior to hospitalization and again within the perioperative interval.

Preoperative Antiseptic Use
To maximize skin antisepsis, patients should begin the process with a minimum of two preoperative showers or skin cleansing procedures at home before coming into the hospital for a procedure. This step supplements, but does not replace, the skin preparation protocols that occur in the hospital setting. The practice is also supported by the Centers for Disease Control and Prevention (CDC), which “strongly recommends” (evidence category 1B) patients shower with an antiseptic agent prior to elective surgeries.[7] In a recent study published in the Journal of the American College of Surgeons, we recommended that to maximize the benefit of the preadmission antiseptic shower, patients should allow the antiseptic solution to remain on the skin for a minimum of two minutes before rinsing, and that a second shower should be taken to further enhance skin antiseptic activity, reducing the microbial skin burden prior to hospital admission.[8]

The traditional formulation of CHG that has been used or the preoperative shower is 4% chlorhexidine gluconate (CHG), which provides high, sustainable levels of CHG on the surface. CHG is safe and has been used in a number of clinical applications, providing a broad-spectrum and long-lasting (residual) antimicrobial activity. Compared to povidone iodine, which has a short duration of antiseptic activity, CHG provides sustainable antiseptic activity on the surface of the skin lasting up to 48 hours and is a valuable element in a step-wise approach to antisepsis that begins pre-hospitalization.[8,9]

An alternative strategy within the ambulatory environment or with patients who find it difficult to shower involves cleansing the surface skin using a 2% CHG-coated polyester cloth (2% Chlorhexidine Gluconate Cloth, Sage Products, Inc.). Following two applications of CHG using the polyester cloth, the skin surface CHG concentrations approaches 2,000ppm (CHG MIC90 for skin staphylococci is 4.8ppm).[8] This innovative device has been shown to reduce the microbial log burden in the groin to a level beyond the prescribed United States Food and Drug Administration (FDA) standards when compared to the traditional 4% CHG perioperative scrub.[9] It has been suggested that the CHG polyester cloth gently exfoliates the skin during application, driving CHG deeper within the recesses of the skin than the traditional 4% CHG skin preparation.

Antiseptic Use Directly Before the Procedure
Once the patient is admitted for surgery, an effective perioperative skin preparation agent is required to ensure optimal skin antisepsis at the time of incision. In the hospital setting, antiseptic products are frequently applied with a hand-held applicator. It is often challenging to use these applicators on patients who are obese due to redundant skin folds; therefore, patience is required when prepping the skin to thoroughly cover all appropriate areas. Embracing the preadmission shower/cleansing strategy gives physicians and their patients an added layer of security in knowing that the skin was prepped preoperatively using a 4% CHG shower or 2% CHG cleansing cloth, resulting in high antiseptic skin surface activity prior to the traditional surgical skin prep performed within the operating room.

For many years, our European colleagues have utilized a two-step process for preoperative skin prepping using CHG followed by “spirits” (alcohol), with the knowledge that CHG is a superior antiseptic compared to povidone iodine and the addition of alcohol provides an immediate killing effect before evaporating.[10] Only recently in the United States have we had a commercially available combination of 2% CHG and 70% isopropyl alcohol in a single applicator device, which has been FDA approved as a surgical skin-prep (ChloraPrep® Patient Preoperative Skin Preparation, CareFusion, San Diego, California). This combination of CHG and alcohol has the clinical benefit of being fast acting with long residual activity, while the applicator is designed to help minimize the hand-to-patient contact, thereby reducing the risk of cross-contamination. Another consideration, which favors the use of this 2% CHG/70% alcohol surgical skin prep, is that the traditional iodine containing skin-preps are inactivated or neutralized by blood and protein-laden fluids, whereas CHG provides continuous antiseptic activity in the presence of these contaminating substances.[11]

Additional Considerations to Prevent HAIs

If hair removal is deemed necessary prior to the surgical procedure, the current standard of practice dictates that the hair is removed using surgical clippers rather than shaving the incisional area with a razor. This practice is endorsed by the CDC and the Surgical Care Improvement Project (SCIP) as shaving is associated with a higher risk of nicks on the skin, leading to skin crevice colonization and the potential for increased infection rates. While there are a number of clipper options available, products that allow for fast, close, wet or dry clipping and have custom blades for enhanced maneuverability are desirable. Disposable sterile blades can also help prevent cross-contamination. Although the clipper power unit (body) is not sterile, some models allow for full submersion in disinfectants, which can make cleaning easier and faster.

Employing two preadmission antiseptic showers or skin cleansings in combination with a perioperative 2% CHG/70% isopropyl alcohol surgical skin prep represents a simplistic yet pragmatic state-of-the-art approach for reducing the risk of surgical site infection in the bariatric patient population. This interventional strategy comes at a time when healthcare institutions find themselves facing potential legislative mandates for reducing the risk of healthcare-associated infections, while often having to assume the fiscal burden for managing these catastrophic adverse outcomes. Skin antisepsis has always been a fundamental cornerstone for reducing postoperative infections and while the bariatric patient may present us with some unique risk reduction challenges, a “layered” approach to skin antisepsis is the appropriate strategy to improve surgical outcomes in the bariatric patient population.

1.    Edmiston CE, Krepel C, Kelly H, et al. Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Surgery. 2004;136:738–747.
2.    Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patient. N Engl J Med. 2001;345:1359–1367.
3.    Joseph B, Genaw J, Carlin A, et al. Perioperative tight glycemic control: the challenge of bariatric surgery patients and the fear of hypoglycemic events. The Permanente Journal. 2007;11;2: 36–39.
4.    Wiener RS, Wiener DC, Larson RJ. Benefits and risk of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008; 300:933–944.
5.    Chan RP, Galas, FR, Hajjar LA, et al. Intensive perioperative glucose control does not improve outcomes of patients submitted to open-heart surgery: a randomized controlled trial. Clinics (Sao Paulo). 2009;64:51–60.
6.    Finfer S, Chittock Dr, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.
7.    Mangram AJ, Horan TC, Pearson ML, et al, The Hospital Infection Control Practice Advisory Committee: Guidelines for the prevention of surgical site infections. Am J Infect Control. 1999;27:97–134.
8.    Edmiston CE Jr, Krepel CJ, Seabrook GR, et al. Preoperative shower revisited: Can high topical antiseptic levels be achieved on the skin surface before surgical admission? J Am Coll Surg. 2008;207:233–239.
9.    Edmiston CE Jr, Seabrook GR, Johnson CP, et al. Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to surgery. Am J Infect Control. 2007;35:89–96.
10.    Saltzman MD, Nuber GW, Gryzla SM, et al. Efficacy of surgical preparation solution in shoulder surgery. J Bone Joint Surgery. 2009;91:1949–1995.
11.    Paulson DS. Chlorhexidine gluconate. In: Paulson DS (ed). Handbook of Topical Antimicrobials: Industrial Applications in Consumer Products and Pharmaceuticals. New York: Marcel Dekker; 2003:117–122.

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