title: Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery. [Does nasal decontamination reduce the incidence of infections after cardiac surgery?]. Surgical site infections following colorectal cancer surgery: a randomized prospective trial comparing common and advanced antimicrobial dressing containing ionic silver [Effects of ASPAN's evidence-based clinical practice guidelines for promotion of hypothermia of patients with total knee replacement arthroplasty]. Total Occlusive Ionic Silver-Containing Dressing vs Mupirocin Ointment Application vs Conventional Dressing in Elective Colorectal Surgery: Effect on Incisional Surgical Site Infection. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Efficacy of surgical preparation solutions in shoulder surgery. Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes Undergoing General Surgery (RABBIT 2 Surgery)
abstract: BACKGROUND Nasal carriers of Staphylococcus aureus are at increased risk for health care-associated infections with this organism . Decolonization of nasal and extranasal sites on hospital admission may reduce this risk . METHODS In a r and omized , double-blind , placebo-controlled , multicenter trial , we assessed whether rapid identification of S. aureus nasal carriers by means of a real-time polymerase-chain-reaction ( PCR ) assay , followed by treatment with mupirocin nasal ointment and chlorhexidine soap , reduces the risk of hospital-associated S. aureus infection . RESULTS From October 2005 through June 2007 , a total of 6771 patients were screened on admission . A total of 1270 nasal swabs from 1251 patients were positive for S. aureus . We enrolled 917 of these patients in the intention-to-treat analysis , of whom 808 ( 88.1 % ) underwent a surgical procedure . All the S. aureus strains identified on PCR assay were susceptible to methicillin and mupirocin . The rate of S. aureus infection was 3.4 % ( 17 of 504 patients ) in the mupirocin-chlorhexidine group , as compared with 7.7 % ( 32 of 413 patients ) in the placebo group ( relative risk of infection , 0.42 ; 95 % confidence interval [ CI ] , 0.23 to 0.75 ) . The effect of mupirocin-chlorhexidine treatment was most pronounced for deep surgical-site infections ( relative risk , 0.21 ; 95 % CI , 0.07 to 0.62 ) . There was no significant difference in all-cause in-hospital mortality between the two groups . The time to the onset of nosocomial infection was shorter in the placebo group than in the mupirocin-chlorhexidine group ( P=0.005 ) . CONCLUSIONS The number of surgical-site S. aureus infections acquired in the hospital can be reduced by rapid screening and decolonizing of nasal carriers of S. aureus on admission . ( Current Controlled Trials number , IS RCT N56186788 . HYPOTHESIS Deep infection after shoulder surgery is a rare but devastating problem . This study tested the hypothesis that the home application of a 2 % chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a st and ard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder . MATERIAL S AND METHODS This r and omized , prospect i ve study evaluated 100 consecutive patients undergoing shoulder surgery . Patients were r and omly assigned to use 2 % chlorhexidine gluconate-impregnated cloths ( treatment group ) or to shower with soap and water before surgery ( control group ) . Cutaneous cultures were taken from the patients ' shoulders in the preoperative holding area . Patients were monitored for 2 months postoperatively for clinical signs of infection . RESULTS In the treatment group vs the control group , the overall positive culture rate was 66 % vs 94 % ( P = .0008 ) , and the positive culture rate for coagulase-negative Staphylococcus was 30 % vs 70 % ( P = .0001 ) . The positive culture rate for Propionibacterium acnes was 46 % in the treatment group vs 58 % in the control group ( P = .32 ) . No infections occurred in any patients at a minimum of 2-months after surgery . DISCUSSION The use of the 2 % chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus , a known causative agent of postoperative shoulder infections . CONCLUSION Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies INTRODUCTION Mupirocin applied to the anterior nares four times daily usually eliminates Staphylococcus aureus , including methicillin resistant , within 48 hours . Prophylactic intranasal mupirocin is safe , inexpensive and effective in reducing the overall sternal wound infection after open-heart surgery . This study was design ed to determine whether decreasing nasal bacterial colonization by applying mupirocin intra nasally decreases mediastinal , sternal , pulmonary and cutaneous infections after open-heart surgery . MATERIAL & METHODS After institutional approval and informed consent , 392 patients were included in a r and omized , prospect i ve study . Nasal cultures were taken for all patients before surgery . Patients were divided in two groups : Group I ( n = 190 ) receiving mupirocin in the anterior nares 4 times daily for 48 hours before surgery ; Group II ( n = 202 ) was the control group . Patients were followed for a month after surgery . All mediastinal , sternal , pulmonary and cutaneous infections were documented and treated with appropriate antibiotics . A Student test for quantitative data and a chi2 test for qualitative data were used for statistical analysis . p < or = 0.05 was considered significant . RESULTS The two groups had the same demographic characteristics and risk factors . Nasal carriage of Staphylococcus was 36.2 % in the two groups . Neither mediastinitis nor sternitis were noticed in any of the two groups . There was no statistical difference between the groups according to the frequency of the cutaneous infections ( Group I : 19/190 - Group II : 13/202 ) and pneumonia ( Group I : 7/190 - Group II : 13/202 ) . In patients who had nasal carriage of Staphylococcus , nasal decontamination has not shown a statistical difference of cutaneous infections of the lower limbs nor pneumonia . Although nasal decontamination reduced the incidence of sternal wound infection ( Gr I 0/190 - Gr II 4/202 ; p = 0.017 ) . Staphylococcus aureus , in the control group , induced more cutaneous infections ( 30.8 % vs 11.7 % ; p = 0.048 ) . CONCLUSION The usage of mupirocin for nasal decontamination before open-heart surgery reduces the incidence of the sternal wound infection , and does not seem to affect the frequency of cutaneous infections of the lower limbs nor pneumonia after this surgery Background An antimicrobial dressing containing ionic silver was found effective in reducing surgical-site infection in a preliminary study of colorectal cancer elective surgery . We decided to test this finding in a r and omized , double-blind trial . Methods Adults undergoing elective colorectal cancer surgery at two university-affiliated hospitals were r and omly assigned to have the surgical incision dressed with Aquacel ® Ag Hydrofiber dressing or a common dressing . To blind the patient and the nursing and medical staff to the nature of the dressing used , scrub nurses covered Aquacel ® Ag Hydrofiber with a common wound dressing in the experimental arm , whereas a double common dressing was applied to patients of control group . The primary end-point of the study was the occurrence of any surgical-site infection within 30 days of surgery . Results A total of 112 patients ( 58 in the experimental arm and 54 in the control group ) qualified for primary end-point analysis . The characteristics of the patient population and their surgical procedures were similar . The overall rate of surgical-site infection was lower in the experimental group ( 11.1 % center 1 , 17.5 % center 2 ; overall 15.5 % ) than in controls ( 14.3 % center 1 , 24.2 % center 2 , overall 20.4 % ) , but the observed difference was not statistically significant ( P = 0.451 ) , even with respect to surgical-site infection grade 1 ( superficial ) versus grade s 2 and 3 , or grade 1 and 2 versus grade 3 . Conclusions This r and omized trial did not confirm a statistically significant superiority of Aquacel ® Ag Hydrofiber dressing in reducing surgical-site infection after elective colorectal cancer surgery . Trial registration Clinical trials.gov : PURPOSE In this study an examination was done of the effects of the American Society of PeriAnesthesia Nurses ( ASPAN ) Evidence -Based Clinical Practice Guidelines on body temperature , shivering , thermal discomfort , and time to achieve normothermia in patients undergoing total knee replacement arthroplasty ( TKRA ) under spinal anesthesia . METHODS This study was an experimental study with a r and omized controlled trial design . Participants ( n=60 ) were patients who underwent TKRA between December 2011 and March 2012 . Experimental group ( n=30 ) received active and passive warming measures as described in the ASPAN 's guidelines . Control group ( n=30 ) received traditional care .  Body temperature , shivering , thermal discomfort , time to achieve normothermia were measured in both groups at 30 minute intervals . RESULTS Experimental group had slightly higher body temperature compared to control group ( p=.002 ) . Thermal discomfort was higher in the experimental group before surgery but higher in the control group after surgery ( p=.034 ) . It decreased after surgery ( p=.041 ) in both groups . Time to achieve normothermia was shorter in the experimental group ( p=.010 ) . CONCLUSION ASPAN 's guidelines provide guidance on measuring patient body temperature at regular intervals and on individualized and differentiated hypothermia management which can be very useful in nursing care , particularly in protecting patient safety and improving quality of nursing BACKGROUND Several pre- and intraoperative factors have been associated with incisional surgical site infection ( SSI ) , but little is known about the influence of postoperative wound care and especially , the use of different dressings on incisional SSI . The aim of this study was to compare 3 methods of wound dressings ( conventional dressing , silver-containing dressing , and mupirocin ointment dressing ) for their ability to prevent SSI , as measured by SSI rates , in patients with colorectal cancer undergoing elective open surgery . STUDY DESIGN A prospect i ve , r and omized study was performed . Inclusion criteria were diagnosis of colorectal neoplasms and plans to undergo elective surgery with curative aims . Patients were r and omized using a 1:1:1 allocation into 3 groups : patients receiving an ionic silver-containing dressing ( ISD ) ( group 1 ) , a mupirocin ointment application ( MOA ) ( group 2 ) , and a conventional dressing ( group 3 or st and ard dressing ) . The primary outcomes variable was occurrence of incisional SSI . Follow-up was 30 days postoperatively . RESULTS A total of 147 patients were included , 49 in each group .  Incisional SSI occurred in 9 patients ( 18.4 % ) in the ISD group , 2 ( 4.1 % ) in the MOA group , and 10 ( 20.4 % ) in the st and ard dressing group ( p = 0.028 ) . Adjusting for multiple comparisons , there were no significant differences between ISD and st and ard dressing groups ; a significant difference was observed between ISD and MOA ( relative risk [ RR ] 4.5 ; 95 % CI ( 1.1 to 19.8 ) ; p = 0.046 ) and between the st and ard group and the MOA group ( RR 5 ; 95 % CI ( 1.2 to 21.7 ) ; p = 0.031 ) . CONCLUSIONS Topical application of mupirocin ointment achieves better results for the prevention of SSI than ionic silver-containing dressing or st and ard dressing in patients undergoing elective open colorectal surgery BACKGROUND Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection ( SSI ) . The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective , but cost and patient compliance may be a barrier . Nasal povidone-iodine solution may provide an alternative to mupirocin . METHODS We conducted an investigator-initiated , open-label , r and omized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of  surgical incision .  The primary study end point was deep SSI within the 3 months after surgery . RESULTS In the modified intent-to-treat analysis , a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group ( P = .1 ) ; S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group ( P = .2 ) . In the per protocol analysis , S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group ( P = .03 ) . CONCLUSIONS Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01313182 PURPOSE We defined the relevant skin flora during genitourinary prosthetic surgery , evaluated the safety of chlorhexidine-alcohol for use on the male genitalia and compared chlorhexidine-alcohol to povidone-iodine in decreasing the rate of positive bacterial skin cultures at the surgical skin site before prosthetic device implantation . MATERIAL S AND METHODS In this single institution , prospect i ve , r and omized , controlled study we evaluated 100 consecutive patients undergoing initial genitourinary prosthetic implantation . Patients were r and omized to a st and ard skin preparation with povidone-iodine or chlorhexidine-alcohol .  Skin cultures were obtained from the surgical site before and after skin preparation . RESULTS A total of 100 patients were r and omized , with 50 in each arm . Pre-preparation cultures were positive in 79 % of the patients . Post-preparation cultures were positive in 8 % in the chlorhexidine-alcohol group compared to 32 % in the povidone-iodine group ( p = 0.0091 ) . Coagulase-negative staphylococci were the most commonly isolated organisms in post-preparation cultures in the povidone-iodine group ( 13 of 16 patients ) as opposed to propionibacterium in the chlorhexidine-alcohol group ( 3 of 4 patients ) . Clinical complications requiring additional operations or device removal occurred in 6 patients ( 6 % ) with no significant difference between the 2 groups . No urethral or genital skin complications occurred in either group . CONCLUSIONS Chlorhexidine-alcohol was superior to povidone-iodine in eradicating skin flora at the surgical skin site before genitourinary prosthetic implantation . There does not appear to be any increased risk of urethral or genital skin irritation with the use of chlorhexidine compared to povidone-iodine . Chlorhexidine-alcohol appears to be the optimal agent for skin preparation before genitourinary prosthetic procedures OBJECTIVE To compare the effects of different skin preparation solutions on  surgical-site infection rates .  DESIGN Three skin preparations were compared by means of a sequential implementation design . Each agent was adopted as the preferred modality for a 6-month period for all general surgery cases . Period 1 used a povidone-iodine scrub-paint combination ( Betadine ) with an isopropyl alcohol application between these steps , period 2 used 2 % chlorhexidine and 70 % isopropyl alcohol ( ChloraPrep ) , and period 3 used iodine povacrylex in isopropyl alcohol ( DuraPrep ) . Surgical-site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative . The primary outcome was the overall rate of surgical-site infection by 6-month period performed in an intent-to-treat manner . SETTING Single large academic medical center . PATIENTS All adult general surgery patients . RESULTS The study comprised 3,209 operations . The lowest infection rate was seen in period 3 , with iodine povacrylex in isopropyl alcohol as the preferred preparation method ( 3.9 % , compared with 6.4 % for period 1 and 7.1 % for period 2 ; P = .002 ) . In subgroup analysis , no difference in outcomes was seen between patients prepared with povidone-iodine scrub-paint and those prepared with iodine povacrylex in isopropyl alcohol , but patients in both these groups had significantly lower surgical-site infection rates , compared with rates for patients prepared with 2 % chlorhexidine and 70 % isopropyl alcohol ( 4.8 % vs 8.2 % ; P = .001 ) . CONCLUSIONS Skin preparation solution is an important factor in the prevention of surgical-site infections .  Iodophor-based compounds may be superior to chlorhexidine for this purpose in general surgery patients BACKGROUND Deep infection following shoulder surgery is a rare but devastating problem . The use of an effective skin-preparation solution may be an important step in preventing infection . The purpose s of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder . METHODS A prospect i ve study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution . Each shoulder was prepared with one of three r and omly selected solutions : ChloraPrep ( 2 % chlorhexidine gluconate and 70 % isopropyl alcohol ) , DuraPrep ( 0.7 % iodophor and 74 % isopropyl alcohol ) , or povidone-iodine scrub and paint ( 0.75 % iodine scrub and 1.0 % iodine paint ) . Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients , to determine the native bacteria around the shoulder , and following skin preparation for all patients . RESULTS Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation . The overall rate of positive cultures was 31 % in the povidone-iodine group , 19 % in the DuraPrep group , and 7 % in the ChloraPrep group . The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group ( p < 0.0001 ) and the DuraPrep group ( p = 0.01 ) . ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region ( p < 0.001 for both ) . No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region . No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up . CONCLUSIONS ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region . Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder OBJECTIVE The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known . RESEARCH DESIGN AND METHODS This r and omized multicenter trial compared the safety and efficacy of a basal-bolus insulin regimen with glargine once daily and glulisine before meals ( n = 104 ) to sliding scale regular insulin ( SSI ) four times daily ( n = 107 ) in patients with type 2 diabetes mellitus undergoing general surgery . Outcomes included differences in daily blood glucose ( BG ) and a composite of postoperative complications including wound infection , pneumonia , bacteremia , and respiratory and acute renal failure . RESULTS The mean daily glucose concentration after the 1st day of basal-bolus insulin and SSI was 145 ± 32 mg/dL and 172 ± 47 mg/dL , respectively ( P < 0.01 ) . Glucose readings < 140 mg/dL were recorded in 55 % of patients in basal-bolus and 31 % in the SSI group ( P < 0.001 ) . There were reductions with basal-bolus as compared with SSI in the composite outcome [ 24.3 and 8.6 % ; odds ratio 3.39 ( 95 % CI 1.50–7.65 ) ; P = 0.003 ] . Glucose < 70 mg/dL was reported in 23.1 % of patients in the basal-bolus group and 4.7 % in the SSI group ( P < 0.001 ) , but there were no significant differences in the frequency of BG < 40 mg/dL between groups ( P = 0.057 ) . CONCLUSIONS Basal-bolus treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients . Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with type 2 diabetes
target: From the patient ’s perspective , an infection delays healing , can increase time away from work or family , and can cause additional pain and complications ( eg , sepsis , long-term disabilities , death ) .
background: urgical site infections ( SSIs ) continue to cause significant patient harm despite many advances in Sinfection prevention .
  The negative effects of SSIs on morbidity , mortality , and the cost of care has kept SSI reduction a top priority for health care organizations worldwide .
  A 2011 systematic review found that approximately 55 % of SSIs in the United States may be preventable by using evidence -based guidelines .