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

    36 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.
    LanguageEnglish
    Pages1027-1033
    Number of pages7
    JournalJAMA Surgery
    Volume150
    Issue number11
    Early online date26 Aug 2015
    DOIs
    Publication statusPublished - Nov 2015

    Fingerprint

    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

    T2 - JAMA Surgery

    JF - JAMA Surgery

    SN - 2168-6254

    IS - 11

    ER -