title: Body-exhaust suit versus occlusive clothing. A randomised, prospective trial using air and wound bacterial counts. The influence of the total body exhaust suit on air and wound contamination in elective hip-operations. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. The Quality of Reporting of Randomized Trials in The Journal of Bone and Joint Surgery from 1988 through 2000 Prevention of postoperative wound infections by covering the surgical field with iodine-impregnated incision drape (Ioban® 2) Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission? Air contamination during skin preparation and draping in joint replacement surgery. Efficacy of surgical preparation solutions in foot and ankle surgery. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections Factors affecting the incidence of postoperative wound infection. Operating room surveillance: a new approach in reducing hip and knee prosthetic wound infections. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. The effect of washing with chlorhexidine soap on wound infection rate in general surgery. A controlled clinical study. Efficacy of surgical preparation solutions in shoulder surgery.
abstract: We r and omly allocated 50 total knee replacements to scrub teams wearing body-exhaust suits ( BES ) or Rotecno occlusive clothing .  The effectiveness of the clothing was assessed using air and wound bacterial counts . Bacteria were recovered from 62 % of wounds ( 64 % BES , 60 % Rotecno ) . The mean air count was 0.5 CFU/ m3 with BES and 1.0 CFU/m3 with Rotecno ( p = 0.014 ) . The mean wound counts were 14 bacteria/wound with BES and eight bacteria/wound with Rotecno ( p = 0.171 ) . There was no correlation between the air and wound counts ( r = -0.011 , Spearman 's ) . The higher air counts suggest that Rotecno occlusive clothing is less effective than BES , but wounds were equally contaminated with both types of clothing suggesting that at very low levels of air contamination the contribution of bacteria to the wound from the air is irrelevant . Even doubling the air counts from 0.5 to 1.0 CFU/m3 had no detectable effect on the wound . This allows a re assessment to be made of other sources of contamination the effect of which would previously have been overwhelmed by contamination from air An evaluation of the effect of total body exhaust clothing on air and wound contamination was made in an operating theatre with a zonal ventilation system . Sixty-four patients who underwent total hip replacement using the Charnley-Müller prosthesis were studied . The members of the surgical team wore total body exhaust suits ( TBE-suit ) , or conventional theatre clothing ( C-clothing ) at alternate operations . Nearly half of the patients in each group were given prophylactic antibiotics . Both the mean and median values of airborne bacteria in the operating theatre were significantly lower during operations with TBE-suits than with conventional theatre clothing . The lowest number , 4.0 cfu/m3 , was found at the site of the operation wound . Cultures from adhesive drapes showed growth in 46 per cent of the C-group and in 43 per cent of the TBE-group sample s. Wound washouts showed growth in 43 per cent of the C-group and in 10 per cent of the TBE-group sample s. Staphylococcus epidermidis was the most frequently isolated bacteria both from adhesive drapes and from wound washouts . The rate of superficial infections was slightly higher when C-clothing was used . Deep infections were found in one patient in the TBE-group and in two patients in the C-group . None of the infected patients had received prophylactic antibiotics The effect of preoperative whole-body washing with chlorhexidine detergent on the incidence of  postoperative wound infection  was assessed in a  placebo-controlled trial of 1989 patients . Patients bathed or showered with chlorhexidine , placebo , or conventional bar soap , on two occasions in the 24 h before operation . The overall infection rate for patients treated with chlorhexidine was 9 % , against 12.8 % in the bar soap and 11.7 % in the placebo groups ; in the ' clean ' surgery group infections were 7.2 % against 10.2 % and 10 % , respectively . The Staphylococcus aureus infection rate in the ' clean ' group was 3 % for chlorhexidine against 6 % for bar soap Background : The purpose of this study was threefold : ( 1 ) to determine the scientific quality of published r and omized trials in the American Volume of The Journal of Bone and Joint Surgery from 1988 through 2000 , ( 2 ) to identify predictors of study quality , and ( 3 ) to evaluate inter-rater agreement in the scoring of study quality with use of a simple scale . Methods : H and search es of The Journal of Bone and Joint Surgery were conducted in duplicate to identify r and omized clinical trials . Of 2468 studies identified , seventy-two ( 2.9 % ) met all eligibility criteria . Two investigators each assessed the quality of the study under blinded conditions and abstract ed relevant data . Results : The mean score ( and st and ard error ) for the quality of the seventy-two r and omized trials was 68.1 % ± 1.6 % ; 60 % ( forty-three ) scored < 75 % . Drug trials had a significantly higher mean quality score than did surgical trials ( 72.8 % compared with 63.9 % , p < 0.05 ) . Regression analysis revealed that cited affiliation with an epidemiology department and cited funding were associated with higher quality scores . Failure to conceal r and omization , to blind outcome assessors , and to describe why patients were excluded result ed in significantly lower quality scores ( p < 0.05 ) , more than the 5 % decrease expected by removal of each item . A priori calculations of sample size were rarely performed in the review ed studies , and only 2 % of the studies with negative results included a post hoc power analysis . The Detsky quality scale met accepted st and ards of interobserver reliability ( kappa , 0.87 ; 95 % confidence interval , 0.70 to 0.95 ) . Conclusions : Few studies published in The Journal of Bone and Joint Surgery were r and omized trials . More than half of the trials were limited by a lack of concealed r and omization , lack of blinding of outcome assessors , or failure to report reasons for excluding patients . Application of st and ardized guidelines for the reporting of clinical trials in orthopaedics should improve quality The literature is used to analyse the significance of the use of iodine-impregnated incision drape ( Ioban ® 2 ) for the prevention of  postoperative wound infections ( SSI ) .  The drape has a microbiocidal effect in vitro . Consequently an antiseptic effect also occurs under the incision drape when it is applied to the skin ; at the same time , bacterial wound contamination is reduced . Overall , based on the efficacy strength of the antiseptic incision drape , a reduction of the SSI rate can , however , be confirmed only with a large sample size . A meta analysis which evaluated four prospect i ve studies and one retrospective study was able to provide significant confirmation of a reduction in the SSI rate . There are no limitations in terms of the biocompatibility of the iodine-impregnated incision drape BACKGROUND Skin asepsis is a sentinel strategy for reducing risk of  surgical site infections .  In this study , chlorhexidine gluconate ( CHG ) skin concentrations were determined after preoperative showering/skin cleansing using 4 % CHG soap or 2 % CHG-impregnated polyester cloth . STUDY DESIGN Subjects were r and omized to one of three shower ( 4 % soap)/skin cleansing ( 2 % cloth ) groups ( n = 20 per group ) : ( group 1 A/B ) evening , ( group 2 A/B ) morning , or ( group 3 A/B ) evening and morning . After showering or skin cleansing , volunteers returned to the investigator 's laboratory where  CHG skin surface concentrations were determined at five separate skin sites . CHG concentrations were compared with CHG minimal inhibitory concentration that inhibits 90 % ( MIC(90 ) ) of staphylococcal skin isolates . RESULTS CHG MIC(90 ) for 61 skin isolates was 4.8 parts per million ( ppm ) . In group 1A , 4 % CHG skin concentrations ranged from 17.2 to 31.6 ppm , and CHG concentrations were 361.5 to 589.5 ppm ( p < 0.0001 ) in group 1B ( 2 % ) . In group 2A ( 4 % ) , CHG levels ranged from 51.6 to 119.6 ppm and 848.1 to 1,049.6 ppm in group 2B ( 2 % ) , respectively ( p < 0.0001 ) . CHG levels ranged from 101.4 to 149.4 ppm in the 4 % CHG group ( group 3A ) compared with 1,484.6 to 2,031.3 ppm in 2 % CHG cloth ( group 3B ) group ( p < 0.0001 ) . Effective CHG levels were not detected in the 4 % CHG group in selected sites in seven ( 35 % ) subjects in group 1A , three ( 15 % ) in group 2A , and five ( 25 % ) in group 3A . CONCLUSIONS Effective CHG levels were achieved on most skin sites after using 4 % CHG ; gaps in antiseptic coverage were noted at selective sites even after repeated application . Use of the 2 % CHG polyester cloth result ed in considerably higher skin concentrations with no gaps in antiseptic coverage . Effective decolonization of the skin before hospital admission can play an important role in reducing risk of surgical site infections Despite the use of ultraclean air , there are still cases of infection in total joint arthroplasty . One possible route by which bacteria may enter the wound is indirectly by contamination of instruments during skin preparation and draping . We found that bacterial air counts were 4.4 times higher during preparation and draping for hip or knee arthroplasty using an unscrubbed , ungowned leg holder than during the operation itself . With the leg holder scrubbed and gowned during preparation and draping , the air counts were reduced but were still 2.4 fold greater than intraoperatively . On some occasions , the air counts during preparation and draping exceeded the st and ards for ultraclean air irrespective of the attire of the leg holder . We recommend that the leg is held by a scrubbed and gowned member of the team . More importantly , we consider that instrument packs should be opened only after skin preparation and draping have been completed BACKGROUND Previous studies have demonstrated higher infection rates following orthopaedic procedures on the foot and ankle as compared with procedures involving other areas of the body . Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery . The purpose of the present study was to evaluate the efficacy of three different surgical skin-preparation solutions in eliminating potential bacterial pathogens from the foot . METHODS A prospect i ve study was undertaken to evaluate 125 consecutive patients undergoing surgery of the foot and ankle . Each lower extremity was prepared with one of three r and omly selected solutions : DuraPrep ( 0.7 % iodine and 74 % isopropyl alcohol ) , Techni-Care ( 3.0 % chloroxylenol ) , or ChloraPrep ( 2 % chlorhexidine gluconate and 70 % isopropyl alcohol ) . After preparation , quantitative culture specimens were obtained from three locations : the hallux nailfold ( the hallux site ) , the web spaces between the second and third and between the fourth and fifth digits ( the toe site ) , and the anterior part of the tibia ( the control site ) . RESULTS In the Techni-Care group , bacteria grew on culture of specimens obtained from 95 % of the hallux sites , 98 % of the toe sites , and 35 % of the control sites . In the DuraPrep group , bacteria grew on culture of specimens obtained from 65 % of the hallux sites , 45 % of the toe sites , and 23 % of the control sites . In the ChloraPrep group , bacteria grew on culture of specimens from 30 % of the hallux sites , 23 % of the toe sites , and 10 % of the control sites . ChloraPrep was the most effective agent for eliminating bacteria from the halluces and the toes ( p < 0.0001 ) . CONCLUSIONS The use of effective preoperative preparation solution is an important step in limiting surgical wound contamination and preventing infection , particularly in foot and ankle surgery . Of the three solutions tested in the present study , the combination of chlorhexidine and alcohol ( ChloraPrep ) was most effective for eliminating bacteria from the forefoot prior to surgery BACKGROUND The actual risk of prosthetic joint infection as a result of dental procedures and the role of antibiotic prophylaxis have not been defined . METHODS To examine the association between dental procedures with or without antibiotic prophylaxis and prosthetic hip or knee infection , a prospect i ve , single-center , case-control study for the period 2001 - 2006 was performed at a 1200-bed tertiary care hospital in Rochester , Minnesota . Case patients were patients hospitalized with total hip or knee infection . Control subjects were patients who underwent a total hip or knee arthroplasty but without a prosthetic joint infection who were hospitalized during the same period on the same orthopedic floor . Data regarding demographic features and potential risk factors were collected . Logistic regression was used to assess the association of variables with the odds of infection . RESULTS A total of 339 case patients and 339 control subjects were enrolled in the study . There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis ( adjusted odds ratio [ OR ] , 0.8 ; 95 % confidence interval [ CI ] , 0.4 - 1.6 ) , compared with the risk for patients not undergoing a dental procedure ( adjusted OR , 0.6 ; 95 % CI , 0.4 - 1.1 ) respectively . Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection ( adjusted OR , 0.9 [ 95 % CI , 0.5 - 1.6 ] and 1.2 [ 95 % CI , 0.7 - 2.2 ] , respectively ) . CONCLUSIONS Dental procedures were not risk factors for subsequent total hip or knee infection . The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection OBJECTIVE To determine whether patients bathed daily with chlorhexidine gluconate ( CHG ) have a lower incidence of  primary bloodstream infections ( BSIs )  compared with patients bathed with soap and water . METHODS The study design was a 52-week , 2-arm , crossover ( ie , concurrent control group ) clinical trial with intention-to-treat analysis . The study setting was the 22-bed medical intensive care unit ( MICU ) , which comprises 2 geographically separate , similar 11-bed units , of the John H. Stroger Jr ( Cook County ) Hospital , a 464-bed public teaching hospital in Chicago , Illinois . The study population comprised 836 MICU patients . During the first of 2 study periods ( 28 weeks ) , 1 hospital unit was r and omly selected to serve as the intervention unit in which patients were bathed daily with 2 % CHG-impregnated washcloths ( Sage 2 % CHG cloths ; Sage Products Inc , Cary , Illinois ) ; patients in the concurrent control unit were bathed daily with soap and water . After a 2-week wash-out period at the end of the first period , cleansing methods were crossed over for 24 more weeks . Main outcome measures included incidences of primary BSIs and clinical ( culture-negative ) sepsis ( primary outcomes ) and incidences of other infections ( secondary outcomes ) . RESULTS Patients in the CHG intervention arm were significantly less likely to acquire a primary BSI ( 4.1 vs 10.4 infections per 1000 patient days ; incidence difference , 6.3 [ 95 % confidence interval , 1.2 - 11.0 ) . The incidences of other infections , including clinical sepsis , were similar between the units . Protection against primary BSI by CHG cleansing was apparent after 5 or more days in the MICU . CONCLUSION Daily cleansing of MICU patients with CHG-impregnated cloths is a simple , effective strategy to decrease the rate of primary BSIs HYPOTHESIS  Surgical site infections ( SSIs ) are a major contributor to patient injury , mortality , and health care costs . Despite evidence of effectiveness of antimicrobials to prevent SSIs , previous studies have demonstrated inappropriate timing , selection , and excess duration of administration of antimicrobial prophylaxis . We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery . DESIGN National retrospective cohort study with medical record review . SETTING Two thous and nine hundred sixty-five acute-care US hospitals . PATIENTS A systematic r and om sample of 34,133 Medicare in patients undergoing coronary artery bypass grafting ; other open-chest cardiac surgery ( excluding transplantation ) ; vascular surgery , including aneurysm repair , thromboendarterectomy , and vein bypass operations ; general abdominal colorectal surgery ; hip and knee total joint arthroplasty ( excluding revision surgery ) ; and abdominal and vaginal hysterectomy from January 1 through November 30 , 2001 . MAIN OUTCOME MEASURES The proportion of patients who had parenteral antimicrobial prophylaxis  initiated within 1 hour before the surgical incision ; the proportion of patients who were given a prophylactic antimicrobial agent  that was consistent with currently published guidelines ; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery . RESULTS An antimicrobial dose was administered to 55.7 % ( 95 % confidence interval [ CI ] , 54.8%-56.6 % ) of patients within 1 hour before incision .  Antimicrobial agents consistent with published guidelines were administered to 92.6 % ( 95 % CI , 92.3%-92.8 % ) of the patients .  Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7 % ( 95 % CI , 40.2%-41.2 % ) of patients . CONCLUSION Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery Staphylococcus aureus ( S. aureus ) is an independent risk factor for orthopaedic surgical site infection ( SSI ) . To determine whether a preoperative decolonization protocol reduces S. aureus SSIs , we conducted a prospect i ve observational study of patients undergoing elective total joint arthroplasty ( TJA ) at our institution , with two control groups . The concurrent control group comprised patients of surgeons who did not participate in the intervention study . The preintervention control group comprised patients of participating surgeons who had undergone elective TJA during the year before the study . Patients in the intervention group were screened preoperatively for S. aureus by nasal swab cultures . S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine bath once daily for 5 days before surgery . All 164 of 636 participants ( 26 % ) who tested positive completed the decolonization protocol without adverse events and had no postoperative S. aureus SSIs at 1-year followup . In contrast , 1330 concurrent control patients had 12 S. aureus infections . If these infections had occurred in the 26 % of patients expected to be nasal carriers of S. aureus at a given time , the infection rate would have been 3.5 % ( 12 of 345 ) in the control group . In addition , the overall infection rate of the participating surgeons , including nonstaphylococcal infections , decreased from 2.6 % during the preintervention period to 1.5 % during the intervention period , translating to an adjusted economic gain of $ 231,741 for the hospital . The data suggest a preoperative decolonization protocol reduces S. aureus SSIs in patients undergoing TJA.Level of Evidence : Level II , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence A prospect i ve study of postoperative wounds was carried out in West Dorset to determine the incidence of infection , describe the time distribution of presentation before and after discharge from hospital and identify possible contributory factors . There were 702 consecutive patients admitted to the study ( 600 in- patients and 102 day cases ) . Fifty one became infected ( 47 in- patients and 4 day cases ) , corresponding to an overall infection rate of 7.3 % . Over 50 % of infections presented during the first week after operation , and almost 90 % were diagnosed within 2 weeks of surgery Twenty-eight ( 55 % ) wounds that became infected presented after hospital discharge . Of 23 specific aetiological variables studied , four ( age , preoperative stay , shaving and the surgeon ) were shown to have a statistically significant association with the development of wound infection . A strong association between the individual surgeon and the development of a wound infection was demonstrated and this supports the need for routine surgical audit A prospect i ve study of surgical wound infections ( SWI ) in hip prosthesis surgery and total hip and knee replacements at two community hospitals with common surgical staffs was begun in May 1982 . The rates of SWI during the first 7 months for four orthopedic surgeons were 9 % ( 3/32 ) for hip prosthesis surgery and 16.7 % ( 3/18 ) for total hip and knee replacement , with 12 % ( 6/50 ) overall . To reduce infections , each orthopedic surgeon agreed to intraoperative surveillance ( IOS ) of two procedures ( hip prosthesis or total hip or knee replacement ) by the infection control nurse at each hospital . Significant IOS findings were too many persons in the operating room ( five to nine persons ) , operating room doors opened frequently ( 25 to 50 times ) , inconsistent use of prophylactic antibiotics , and excessive conversation . In January 1984 , IOS data and recommendations were shared with each orthopedic surgeon , the operating room staff , and the anesthesia personnel . Subsequently , a statistically significant drop in SWI was realized for total hip and knee replacement ( 1/36 versus 5/36 , p = 0.05 ) and overall ( 3/73 versus 14/116 , p = 0.05 ) . The drop in SWI for hip prosthesis surgery was not statistically significant ( 2/37 versus 9/80 , p greater than 0.10 ) . IOS and individualized communication were effective in reducing SWI BACKGROUND Postoperative surgical site infections ( SSIs ) are a common complication of joint surgery . Prevention depends on adequate preoperative skin antisepsis . In previous studies , use of a 2 % chlorhexidine gluconate ( CHG ) no-rinse cloth reduced SSI rates in general surgery patients . METHODS Patients admitted for a total joint procedure used a skin antisepsis protocol incorporating 2 % CHG no-rinse cloths to do a site-specific wash on the night before surgery and in the holding area just before surgery . RESULTS In the 3 quarters before implementation of the protocol , the SSI rate was 3.19 % . In the 3 quarters after the 2 % CHG cloth was introduced , the SSI rate decreased to 1.59 % , representing a 50.16 % reduction in SSIs . CONCLUSIONS The rate of SSI was cut in half after the introduction of 2 % CHG no-rinse cloths in the place of a povidone-iodine ( Betadine ) skin antiseptic in orthopaedic patients undergoing total joint procedures . Further testing using r and omization comparative protocol s are required to conclude that the decreased SSI was in fact a direct result of the 2 % CHG protocol To determine the value of ultraclean air in operating rooms , 8,052 operations for total hip- or knee-joint replacement were followed up for 1 - 4 years . For operations done in ultraclean air , bacterial contamination of the wound , deep joint sepsis , and major wound sepsis were substantially less than for operations done in conventionally ventilated rooms . Sepsis was also less frequent when prophylactic antibiotics had been given . The two pre caution s acted independently so that the incidence of sepsis after operation in ultraclean air and with antibiotics was much less than that when either was used alone . Wound sepsis was associated with an enhanced risk of joint sepsis . Staphylococcus aureus was the commonest joint pathogen , but infections with other organisms , often considered to be of low pathogenicity , were almost as numerous . Most S. aureus infections were traced to sources in the operating room Postoperative wound infections in clean surgery were studied to compare the effect of preoperative whole body disinfection with chlorhexidine soap with that of local washing and no washing at all , respectively . The study includes 1530 operations for biliary tract disease , inguinal hernia and breast cancer . The overall infection rate was 3.4 % . Among patient who had a preoperative shower with Chlorhexidine the wound infection rate was significantly reduced 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
target: Newer infection prevention techniques , such as preoperative antiseptic scrubbing , are affected and may help reduce the infection rate , while traditionally accepted methods of prophylaxis such as laminar-flow operating rooms and body exhaust suits may raise the infection rate
background: Despite advances in our underst and ing of surgical site infections following total joint arthroplasty , this serious surgical complication continues to represent a substantial economic burden for the patient , the treating institution and the healthcare system .
  After increasing for the past decade , infection rates have stabilized at 1.6 % ; however , the total cost is projected to increase with the total number of revision procedures performed .