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

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June 2009KUWAIT MEDICAL JOURNAL 105Table 1: Clinical characteristics of patients in the studyBiodataClinical CharacteristicsIndications for cystoscopyPCa + BPH **TCC BladderCheck cystoscopyURS + DormiaJ stent InsertUnderlying diseasesNoneDiabetesCreatinine > 250 µmol/LUrethral catheter ***Post renal TPXPrevious hospital admissionNone< 7 days8-15 days> 15 daysPost-op septicemiaPatient CatagoryGroup - 1(n = 114)Age* (Mean)yrs: 54Range: 13-85n %364513119713271356429201831.639.511.49.77.962.328.16.111.44.456.125.417.50.97.1Group 2(n = 117)Age* (Mean)yrs: 55.3Range: 20-79n %p-valueBlood agar (Oxoid) supplemented with gentamicin75 ug/ml, vitamin K1 1 µg/ml, haemin 1 µg/ml andL-cysteine HCL 5 µg/ml and plain Blood agar (Bloodagar base, [Oxoid], plus 5% blood). The second swabwas inoculated onto the surface of similar media.A set of inoculated Brucella agar, gentamicin Bloodagar and plain Blood agar plates were incubatedfor 2-5 days anerobically in jars rendered anerobicusing the Anoxomat WS 8000 machine (MARTMicrobiology, Holland). The MacConkey andanother Blood agar were incubated in air at 37 o C for24 hour. Representative colonies were gram-stainedand identified by the automated VITEK ID system(BioMerieux Inc., Hazelwood, MO, USA) and API20A (BioMerieux, Inc., Marcy Etiole, France). Sterileculture meant no growth. Swab colonization wasdefined as a colony count ≥ 10 per plate. Significantbacterial colonization of the perineum was definedas positive culture with greater than 10 2 cfu/ml oforganisms [14] .Statistical AnalysisThe data were analyzed using the statisticalsoftware SPSS for Windows version 12.0.The chi square (χ 2 ) test was used to examine theassociation between two categorical variables, andthe normal Z test was used to assess the differencebetween two proportions. A p-value of < 0.05 was used404311158773291436923223334.236.89.412.86.865.827.47.712.02.659.019.718.82.62.6 0.01* Our unit does not operate on pediatric patients (age < 12 years);** For either channel TURP for prostate cancer (PCa) or TURPfor BPH; *** Some patients had systemic diseases and were onurethral cathetersas a cut- off level for statistical significance. A p-valuefor trend was also calculated where appropriate.RESULTSA total of 231 patients, randomly assigned intogroup-1 (114 patients) and group-2 (117 patients),were enrolled for this study. The results of the biodataanalysis are shown in Table 1. There was nostatistically significant difference in the distribution ofpatients, indications for surgery, presence of systemicdiseases and previous hospital admissions betweenthe two groups. The average ages were 54 years ingroup-1 and 55.3 years in group-2. There were higherand significant number of patients who developedbacteremia / septicemia in group-1 (8; 7.1%) versus(3; 2.6%) in group-2, (p < 0.01).Tables 2 and 3 show the results of cultured swabspecimens obtained from the two groups of patients.Culture of specimens A obtained from 40 (35.1%) outof 114 patients in group-1 and 74 (63%) out of 117patients in group-2 yielded positive bacterial growth.In contrast, specimen B cultures yielded positivegrowth only in 8 (7%) and 6 (5.1%) patients in groups 1and 2, respectively, a statistically significant reductionin the number of patients with persistent bacterialflora in the perineum post-antiseptic disinfection(p < 0.001). All these specimens also yielded morethan 3 log10 cfu/ml reduction in colony counts (p
106Comparative Efficacy of Two Methods of Skin Preparation of the Perineal and Genital Skin ...June 2009Table 3: The bacteria isolates from all patients in Groups 1 and 2(N = 231).Micro-organisms No. of patients (N = 231) %Gram -veE. coliKlebs. pneumoniaeProteus mirabilisPseudomonas sppE. faecalis *Sub TotalGram +veS. haemolyticusS. epidermidisS. hominisS. warneriOthersSub TotalGross TotalGoup - 1n = 63513121028104295363Goup - 2n = 76Gross Totaln = 139DISCUSSIONThe ideal antiseptic is one that is rapidly lethalto all forms of bacteria and their spores, capableof bactericidal activity for a prolonged period,has no injurious effects on wound tissues or skin,delineates the operation site and is easily applied andremoved [15] . The antiseptic used in skin preparationsand the sequence in which they are used is a matterof individual surgeon’s preference with variationsfrom unit to unit and even within the same surgicalunit as shown by McGrath and McCory [16] in asurvey of pre-operative skin preparation practicesin surgical units and among surgeons in NorthernIreland. The outcome of our current study seemsto justify our unit’s policy of using Savlon® as theantiseptic of choice for perineal skin disinfectionprior to endoscopic procedures as its use wasassociated with significant reduction in the numberof patients with culture-positive bacteria as well as inthe quantity of the bacterial isolates as demonstratedin specimens B compared with samples A in bothgroups of patients. Our study further demonstratedthat instead of using Savlon® alone to clean threetimes, the addition of an iodine-based antisepticagent like Betadine® appears to guarantee betterand more efficient disinfection. The use of Savlon®twice followed by further disinfection with Betadinereduced positive microbiological culture rate to 2.6%in swab C of group-2 patients, compared to 11.4% ingroup-1 (p < 0.001). This is because iodine containingantiseptics like Betadine®, in addition to havingstrong bacteriostatic activity are also known to kill040105281546871765532215563588171241393.63.62.21.41.410.840.325.25.85.812.289.2100Over all positive culture 139/231 (60.2%) patients* Two patients had E. faecalis + E.coli isolated from the perinealswab. Both patients were on urethral catheter for more than 28days before surgeryTable 4: Distribution of bacterial isolates before and after skinpreparation with antisepticsBacterial isolatesGram +veS. haemolyticusS. epidermidisS. hominisS. warneriOthersGram –veE. coli *Klebsiella sppProteus mirabilisPsuedomonas sppE. faecalis*Total no.of patientsTotal (%)No. of patients with positive culture in specimensGroup - 1 (n = 114) Group - 2 (n = 117)A B C A B C1783155020243(35.1)10012011107(7.1)bacteria, fungi, viruses and spores [17,18] . The bacteriaisolation rates from the specimens of the two patientgroups were significantly reduced (p < 0.001) postdisinfectionof the perineum and genitalia.In this study, our patients had about six-foldhigher isolation rates of Gram-positive bacteriathan the Gram-negative bacteria, a finding that wasstatistically significant (p < 0.001). Of these Grampositivebacteria, S.haemolyticus was by far the isolatemost frequently present in the perineum of thesepatients, including those with or without underlyingco-morbidity. This finding is essentially similar to thereports of Magera et al [1] and Larson et a l[19] which alsofound S.haemolyticus as the commonest isolate in theirpatients compared with S. hominis in controls. The nextfairly common isolate was S.epidermidis but we did notisolate S. hominis or S.aureus from any of the patientswhich essentially also supports earlier report [19] . Ofparticular concern are the high isolation rates of thecoagulase-negative staphylococci (CoNS) whichare increasingly becoming important in nosocomialinfections and infections in immunosuppressedindividuals.Post-operative septicemia occurred in morepatients in group-1 compared to group-2, althoughthe difference was not statistically significant. Allthe patients had endoscopic procedures; thereforethey would be expected to have a low septicemiarate. Importantly, the efficacy of adding Betadineto the perineal skin antiseptic preparation regimenis demonstrated by the drastic reduction in thenumber of patients with positive perineal cultureand the bacterial load post-disinfection as well as thesignificant lower septicemia rate in group B patients.1021000000013(11.4)281546190401076(63)32001000006(5.1)11001000003(2.6)*E. faecalis and E. coli isolated from the perineal swabs of twopatients who were on indwelling urethral catheter for more than28 days prior to surgery
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