Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients

Charles E. Edmiston, Cheong J. Lee, Candace J. Krepel, Maureen Spencer, David Leaper, Kellie R. Brown, Brian D. Lewis, Peter J. Rossi, Michael J. Malinowski, Gary R. Seabrook

Research output: Contribution to journalArticle

41 Citations (Scopus)

Abstract

Importance
To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection.

Objectives
To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation.

Design, Setting, and Participants
A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance.

Intervention
Preadmission showers using chlorhexidine gluconate, 4%.

Main Outcomes and Measures
The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing.Results The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses.

Conclusions and Relevance
A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.
Original languageEnglish
Pages (from-to)1027-1033
Number of pages7
JournalJAMA Surgery
Volume150
Issue number11
Early online date26 Aug 2015
DOIs
Publication statusPublished - Nov 2015

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Local Anti-Infective Agents
Skin
chlorhexidine gluconate
Volunteers
Antisepsis
Surgical Wound Infection
Health Facilities
Tertiary Care Centers
Analysis of Variance
Healthy Volunteers
Outcome Assessment (Health Care)

Cite this

Edmiston, Charles E. ; Lee, Cheong J. ; Krepel, Candace J. ; Spencer, Maureen ; Leaper, David ; Brown, Kellie R. ; Lewis, Brian D. ; Rossi, Peter J. ; Malinowski, Michael J. ; Seabrook, Gary R. / Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients. In: JAMA Surgery. 2015 ; Vol. 150, No. 11. pp. 1027-1033.
@article{a1a3ce5ac1e642c3b9e911f5800bed56,
title = "Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4{\%}, in Surgical Patients",
abstract = "Importance To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection.Objectives To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation.Design, Setting, and Participants A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4{\%}, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4{\%}, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance.Intervention Preadmission showers using chlorhexidine gluconate, 4{\%}.Main Outcomes and Measures The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4{\%}, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4{\%}; duration (number of showers); and timing (pause) before rinsing.Results The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses.Conclusions and Relevance A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4{\%}, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.",
keywords = "Pre-operative skin cleansing, Pre-operative showering, Infection reduction, Chlorhexidine gluconate",
author = "Edmiston, {Charles E.} and Lee, {Cheong J.} and Krepel, {Candace J.} and Maureen Spencer and David Leaper and Brown, {Kellie R.} and Lewis, {Brian D.} and Rossi, {Peter J.} and Malinowski, {Michael J.} and Seabrook, {Gary R.}",
year = "2015",
month = "11",
doi = "10.1001/jamasurg.2015.2210",
language = "English",
volume = "150",
pages = "1027--1033",
journal = "JAMA Surgery",
issn = "2168-6254",
publisher = "American Medical Association",
number = "11",

}

Edmiston, CE, Lee, CJ, Krepel, CJ, Spencer, M, Leaper, D, Brown, KR, Lewis, BD, Rossi, PJ, Malinowski, MJ & Seabrook, GR 2015, 'Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients', JAMA Surgery, vol. 150, no. 11, pp. 1027-1033. https://doi.org/10.1001/jamasurg.2015.2210

Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients. / Edmiston, Charles E.; Lee, Cheong J.; Krepel, Candace J.; Spencer, Maureen; Leaper, David; Brown, Kellie R.; Lewis, Brian D.; Rossi, Peter J.; Malinowski, Michael J.; Seabrook, Gary R.

In: JAMA Surgery, Vol. 150, No. 11, 11.2015, p. 1027-1033.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Evidence for a Standardized Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4%, in Surgical Patients

AU - Edmiston, Charles E.

AU - Lee, Cheong J.

AU - Krepel, Candace J.

AU - Spencer, Maureen

AU - Leaper, David

AU - Brown, Kellie R.

AU - Lewis, Brian D.

AU - Rossi, Peter J.

AU - Malinowski, Michael J.

AU - Seabrook, Gary R.

PY - 2015/11

Y1 - 2015/11

N2 - Importance To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection.Objectives To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation.Design, Setting, and Participants A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance.Intervention Preadmission showers using chlorhexidine gluconate, 4%.Main Outcomes and Measures The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing.Results The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses.Conclusions and Relevance A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

AB - Importance To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection.Objectives To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation.Design, Setting, and Participants A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance.Intervention Preadmission showers using chlorhexidine gluconate, 4%.Main Outcomes and Measures The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing.Results The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses.Conclusions and Relevance A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.

KW - Pre-operative skin cleansing

KW - Pre-operative showering

KW - Infection reduction

KW - Chlorhexidine gluconate

UR - http://jamanetwork.com/journals/jamasurgery

U2 - 10.1001/jamasurg.2015.2210

DO - 10.1001/jamasurg.2015.2210

M3 - Article

VL - 150

SP - 1027

EP - 1033

JO - JAMA Surgery

JF - JAMA Surgery

SN - 2168-6254

IS - 11

ER -