June 09-41-2.indd - Kma.org.kw

More documents

Recommendations

Info

June 2009KUWAIT MEDICAL JOURNAL 103Original ArticleComparative Efficacy of Two Methods ofSkin Preparation of the Perineal and GenitalSkin of Male Urological PatientsElijah O Kehinde 1 , Wafaa Jamal 2 , Yousif Ali 1 , Fathima Khodakhast 2 , Mohammed Sahsah 1 , Vincent O Rotimi 21Departments of Surgery (Division of Urology) and 2 Microbiology, Faculty of Medicine, Kuwait University, KuwaitABSTRACTKuwait Medical Journal 2009; 41 (2): 103-107Objective: To compare the efficacy of two methods of skinantiseptic preparations of the genitalia and perineum inmale urological patientsDesign: Prospective studySetting: Mubarak Hospital, KuwaitSubjects: Adult male patients of two study groupsnumbering 114 (group-1) and 117 (group-2) admitted forcystoscopic proceduresIntervention: The perineum and genitalia of patients inboth groups were prepared by applying chlorhexidinecetrimidemixture (CCM) and CCM plus povidone-iodinesolution respectively.Main Outcome Measures: Swab specimens were obtained fromthe perineum and genitalia, before cleaning and disinfection(specimen A), after disinfection and draping (specimen B) andafter the completion of the operative procedure (specimenC). Specimens were cultured on appropriate media andrepresentative colonies identified by standard methods.Results: In groups 1 and 2, the A specimen yielded bacterialgrowth in 35.1 and 63% of patients, respectively. Thecommonest isolates in both groups were Gram-positivebacteria (89.2%) while Gram-negative bacteria accounted foronly 10.8%. The B and C specimens in group-1 yielded positivebacterial culture in 7.1 and 11.4% patients respectively. Ingroup-2, specimens B and C yielded bacterial growth in 5.1and 2.6% patients respectively. In both groups, there wasa significant reduction of patients with culture-positive Bspecimens after skin disinfection (p < 0.001). The isolationrate of bacteria in specimen C in group-2 was significantlylower than group-1 patients (p < 0.001).Conclusion: The addition of povidone-iodine to the CCMbased regimen of perineal skin antiseptic preparation isassociated with longer and more effective skin disinfectionin male urological patients.KEY WORDS: antiseptics, bacterial flora, male patients, perineum, skin preparationINTRODUCTIONThe perineal route is increasingly being usedin male urological patients for diagnostic andtherapeutic procedures. These procedures rangefrom transperineal prostate biopsy to insertion ofartificial urinary sphincter (AUS) for stress urinaryincontinence [1] . Although it is generally assumedthat the perineum is often heavily contaminatedwith microorganisms derived from the rectum, thereis paucity of information in the literature regardinginfectious complications after performing diagnosticor therapeutic maneuvers via the percutaneoustransperineal route. With increasing use of theperineal route in urological practice, it is essentialto study the resident bacterial flora of the maleperineum so as to provide baseline data that couldhelp in predicting the causative agents in post-operative perineal infections and possibly helpin developing a policy for appropriate antibioticprophylaxis or empirical treatment of such infections.This is extremely important when implants like AUSare inserted in the perineum. It has been shown thatinfection of the prosthetic implant is almost alwaysdue to organisms that are part of the patient’s skinflora, with Staphylococcus spp. being the commonestinfecting organisms [1-4] . The prevention of surgical siteinfections (SSIs) has helped to revolutionize surgeryfrom a practice plagued by frequent infections anddeath into one that is more acceptable in the disciplinetoday. However, infections related to surgery continueto remain a problem [5,6] .Data from the USA Center for Disease Control andPrevention (CDC), through the National NosocomialInfections Surveillance (NNIS) System, indicate thatAddress correspondence to:Prof Elijah O Kehinde, MBBS, FRCS, MD, Department of Surgery (Division of Urology), Faculty of Medicine, Kuwait University, P.O. Box24923, Safat - 13110, Kuwait. Tel: 00 965 2531 9475, Fax: 00 965 2531 9597, E-mail: ekehinde@hsc.edu.kw
104Comparative Efficacy of Two Methods of Skin Preparation of the Perineal and Genital Skin ...June 2009SSIs are the third most common infection reported,accounting for 14-16% of all nosocomial infections [5,6] .Evidence also shows that SSIs are the most commonnosocomial infection in surgical patients [7] . In addition,apart from costlier hospital stay, patients who developSSIs carry an overall two-fold higher mortality rate,which is independent of their initial surgical risk andother survival predictors [8-11] . Thus, the preventionof this surgical complication represents a significantimpact not only on cost and quality of life but also onmortality.The goal of surgical prophylaxis is not to sterilizea patient but rather to decrease the bacterial burdenat the surgical site. Prophylaxis augments the host’snatural immune defense mechanisms by increasingthe magnitude of a bacterial inoculum needed tocause an infection [12] . Since the cause of post-operativeinfection can be multifactorial, so the preventionefforts should be multifactorial as well. Apart fromthe appropriate use of prophylactic antibiotics toreduce SSIs, other factors that are important includeunderstanding the microbiology of the surgical siteand resultant infections [13] . In most instances of SSIs,the patient’s endogenous flora is largely the mainetiological factor [13] . Theoretically, the combinationof surgical site disinfection and appropriate systemicprophylactic antibiotics should decrease the chancesof wound infection. However, the use of pre-operativecleansing with an antibacterial solution, such aschlorhexidine or other antiseptics has been shown todecrease the bacterial burden of normal skin flora [5,6] .Unfortunately, this has not been definitely shown totranslate into decreased rates of SSIs [5] . Hence, the aimof this study was to compare the efficacy of a singleantiseptic versus combined antiseptic on perinealskin preparation.SUBJECTS AND METHODSThe PatientsBetween 2003 and 2007, all consecutive malepatients undergoing in-patient cystoscopic proceduresincluding transurethral resection of the prostate(TURP) and transurethral resection of bladder tumor(TURBT) in the urology unit of our hospital wereincluded in this study. Informed consent was obtainedfrom each patient after careful explanation of thescope of the study. In addition, approval was obtainedfrom the local Ethics Committee. The biodata of eachpatient, including age and underlying diseases, werecarefully recorded in a protocol sheet. Adult malein-patients undergoing cystoscopic procedures wererandomized into two groups for perineal and genitalskin disinfection. Patients were anesthetized and thenplaced in the lithotomy position on the operating table.In group-1 patients, the perineal and genital areas wasscrubbed three times using savlon® (chlorhexidinecetrimide mixture [CCM]) only. In group-2 patients,the area was scrubbed twice initially using savlon ®and a third time with betadine® (povidone-iodinesolution).The SpecimensBefore scrubbing the perineum and genitals withantiseptics described above, specimens were takenfrom a midline perineum between the root of the penisand 5 cm from the anal orifice using commerciallyavailable albumin-coated sterile cotton wool swab(Medical Wire and Equipment Co Ltd, Corsham,Wilshire, England). The perineum was rubbed upand down 4-6 times with the same swab and thendipped into semisolid Amies’ transport medium.This first swab specimen was labeled specimenA. After application of the antiseptic regimen anddraping of the patient, a second specimen labeledB was obtained. On completion of the surgicalprocedure and after removal of all drapes, but beforethe patients limbs were removed from the stirrups, athird swab specimen labeled C was taken. All swabspecimens were taken in duplicates. Time takento complete the surgical procedure was carefullyrecorded. All patients received antibiotic prophylaxisprior to undergoing surgical procedures. Thisconsisted of intravenous amikacin 500 mg in patientswith normal renal function or ceftriaxone 2 g in thosewith significant renal impairment (serum creatinine> 250 µmol/l). All specimens were transportedimmediately to the Anerobic Reference and HospitalInfection Laboratory (Department of Microbiology,Kuwait University, Kuwait) and processed withinone hour of collection.The temperature chart of patients was checked 24and 48 hours after the surgical procedures. Patientswith temperature > 38 o C had urine and blood culturestaken and were treated using appropriate antibiotics.Microbiologic InvestigationIn the laboratory one of the duplicate swabs wasplaced in 2 ml sterile thioglycolate broth (Oxoid,Basingstoke, Hampshire, UK) in sterile universalbottles and vigorously vortexed. Viable count wasperformed on the eluted suspension by serial 10-folddilutions of 100 µl samples in sterile Eppendorf tubescontaining 900 µl of appropriate sterile broth with afinal dilution ranging from 10 -1 to 10 -8 . Dried agar plateswere marked into six sectors, and three 10 µl aliquots ofeach dilution were plated onto the three sectors. Oncedry, plates were incubated in appropriate incubatorsovernight at 37 o C. Colonies were counted in sectorscontaining a measurable number in triplicate and thenumber of colony forming units per millilitre (cfu/ml)calculated. The other swab was routinely streaked ontoa set of selective and non-selective media includingMacConkey agar (Oxoid, Basingstoke, UK), Brucellaagar (Oxoid) supplemented with 5% horse blood,
Page 2 and 3: Vol. 41 No. 1KUWAIT MEDICAL JOURNAL
Page 4: KUWAIT MEDICAL JOURNALKUWAIT MEDICA
Page 8 and 9: June 2009KUWAIT MEDICAL JOURNAL 91E
Page 10 and 11: June 2009KUWAIT MEDICAL JOURNAL 93R
Page 12 and 13: June 2009KUWAIT MEDICAL JOURNAL 95O
Page 14 and 15: June 2009KUWAIT MEDICAL JOURNAL 97c
Page 16: June 2009KUWAIT MEDICAL JOURNAL 99p
Page 22 and 23: June 2009KUWAIT MEDICAL JOURNAL 105
Page 70 and 71:
June 2009KUWAIT MEDICAL JOURNAL 153
Page 72 and 73:
Page 74 and 75:
June 2009400 mg/kg/day for five day
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
March 2009KUWAIT MEDICAL JOURNAL 16
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
show all

June 09-41-2.indd - Kma.org.kw

Create successful ePaper yourself

Delete template?

Save as template?