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