Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures

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  • 1 Departments of Neurological Surgery,
  • 2 Hospital Epidemiology and Infection Control, and
  • 3 Hospital Medicine, University of California, San Francisco, California
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OBJECTIVE

Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery.

METHODS

In November 2013, a preoperative CHG shower protocol was implemented at the authors’ institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates.

RESULTS

The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67–13.1; p = 0.15).

CONCLUSIONS

This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

ABBREVIATIONS ASA = American Society of Anesthesiologists; CHG = chlorhexidine gluconate; SSI = surgical site infection.

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Contributor Notes

Correspondence Andrew K. Chan: University of California, San Francisco, CA. andrew.chan@ucsf.edu.

S.G.A. and C.S.E. contributed equally to this work.

INCLUDE WHEN CITING Published online April 30, 2021; DOI: 10.3171/2020.10.JNS201255.

Disclosures Dr. Chan receives support for non–study-related research from Orthofix Medical, Inc. Dr. Mummaneni is a consultant for DePuy Synthes, Globus, and Stryker; has direct stock ownership in Spinicity/ISD; receives support for non–study-related research from AO Spine, ISSG, and NREF; receives royalties from DePuy Synthes, Thieme Publishers, and Springer Publishers; and has grants from AO Spine and ISSG. Dr. Chang receives funding from the National Institutes of Health (grants R01-DC012379, R00-NS065120, and DP2-OD00862) and the Esther A. and Joseph Klingenstein Fund. Dr. Larson received honoraria from Medtronic, grants from Voyager Therapeutics, and nonfinancial support from MRI Interventions. Dr. Starr is a consultant for Medtronic and Boston Scientific and receives research support from Medtronic. Dr. McDermott is a consultant for Stryker.

  • 1

    Ban KA, Minei JP, Laronga C, . American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):5974.

    • Search Google Scholar
    • Export Citation
  • 2

    Anderson DJ, Podgorny K, Berríos-Torres SI, . Infection control & hospital epidemiology strategies to prevent surgical site infections in acute care hospitals: 2014 update strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol Infect. 2014;3535(356):605627.

    • Search Google Scholar
    • Export Citation
  • 3

    Urban JA. Cost analysis of surgical site infections. Surg Infect (Larchmt). 2006;7 (suppl 1):S19S22.

  • 4

    Napolitano LM. Decolonization of the skin of the patient and surgeon. Surg Infect (Larchmt). 2006;7(Suppl 3):s-3s-15.

  • 5

    Chan AK, Ammanuel SG, Chan AY, . Chlorhexidine showers are associated with a reduction in surgical site infection following spine surgery: an analysis of 4266 consecutive surgeries. Neurosurgery. 2019;85(6):817826.

    • Search Google Scholar
    • Export Citation
  • 6

    Zywiel MG, Daley JA, Delanois RE, . Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty. Int Orthop. 2011;35(7):10011006.

    • Search Google Scholar
    • Export Citation
  • 7

    Edmiston CE Jr, Okoli O, Graham MB, . Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. AORN J. 2010;92(5):509518.

    • Search Google Scholar
    • Export Citation
  • 8

    Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthop Nurs. 2009;28(3):141145.

    • Search Google Scholar
    • Export Citation
  • 9

    Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2015;2015(2):CD004985.

    • Search Google Scholar
    • Export Citation
  • 10

    Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013;41(2):167173.

    • Search Google Scholar
    • Export Citation
  • 11

    Marmor R, El-Kareh R, Abeles S, . Home CHG bathing component of perioperative SSI prevention bundle independently decreases infection risk. Presented at: American College of Surgeons 2017 Annual Clinical Congress; October 2017; San Diego, CA.

    • Search Google Scholar
    • Export Citation
  • 12

    Marmor R, El-Kareh R, Abeles S, . Increased OR traffic is not associated with increased SSIs. Presented at: 2017 American College of Surgeons Quality and Safety Conference; July 2017; New York, NY.

    • Search Google Scholar
    • Export Citation
  • 13

    Hamou HA, Kotliar K, Tan SK, . Surgical nuances and placement of subgaleal drains for supratentorial procedures-a prospective analysis of efficacy and outcome in 150 craniotomies. Acta Neurochir (Wien). 2020;162(4):729736.

    • Search Google Scholar
    • Export Citation
  • 14

    Lietard C, Thébaud V, Besson G, Lejeune B. Risk factors for neurosurgical site infections: an 18-month prospective survey. J Neurosurg. 2008;109(4):729734.

    • Search Google Scholar
    • Export Citation
  • 15

    Choi SY, Yoon SM, Yoo CJ, . Necessity of surgical site closed suction drain for pterional craniotomy. J Cerebrovasc Endovasc Neurosurg. 2015;17(3):194202.

    • Search Google Scholar
    • Export Citation
  • 16

    Cassir N, De La Rosa S, Melot A, . Risk factors for surgical site infections after neurosurgery: a focus on the postoperative period. Am J Infect Control. 2015;43(12):12881291.

    • Search Google Scholar
    • Export Citation
  • 17

    Kim T, Han JH, Kim HB, . Risk factors of surgical site infections after supratentorial elective surgery: a focus on the efficacy of the wound-drain-tip culture. Acta Neurochir (Wien). 2013;155(11):21652170.

    • Search Google Scholar
    • Export Citation
  • 18

    Buchanan IA, Donoho DA, Patel A, . Predictors of surgical site infection after nonemergent craniotomy: a nationwide readmission database analysis. World Neurosurg. 2018;120:e440e452.

    • Search Google Scholar
    • Export Citation
  • 19

    Abode-Iyamah KO, Chiang HY, Winslow N, . Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty. J Neurosurg. 2018;128(4):12411249.

    • Search Google Scholar
    • Export Citation
  • 20

    Martin ET, Kaye KS, Knott C, . Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2016;37(1):8899.

    • Search Google Scholar
    • Export Citation
  • 21

    Jiménez-Martínez E, Cuervo G, Hornero A, . Risk factors for surgical site infection after craniotomy: a prospective cohort study. Antimicrob Resist Infect Control. 2019;8(1):69.

    • Search Google Scholar
    • Export Citation
  • 22

    Schipmann S, Akalin E, Doods J, . When the infection hits the wound: matched case-control study in a neurosurgical patient collective including systematic literature review and risk factors analysis. World Neurosurg. 2016;95:178189.

    • Search Google Scholar
    • Export Citation
  • 23

    Fang C, Zhu T, Zhang P, . Risk factors of neurosurgical site infection after craniotomy: a systematic review and meta-analysis. Am J Infect Control. 2017;45(11):e123e134.

    • Search Google Scholar
    • Export Citation
  • 24

    Sherrod BA, Johnston JM, Rocque BG. Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College of Surgeons National Surgical Quality Improvement Program. J Neurosurg Pediatr. 2016;18(3):350362.

    • Search Google Scholar
    • Export Citation
  • 25

    Han C, Song Q, Ren Y, . Dose-response association of operative time and surgical site infection in neurosurgery patients: a systematic review and meta-analysis. Am J Infect Control. 2019;47(11):13931396.

    • Search Google Scholar
    • Export Citation
  • 26

    Bydon M, Abt NB, De la Garza-Ramos R, . Impact of resident participation on morbidity and mortality in neurosurgical procedures: an analysis of 16,098 patients. J Neurosurg. 2015;122(4):955961.

    • Search Google Scholar
    • Export Citation
  • 27

    Lim S, Parsa AT, Kim BD, . Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. J Neurosurg. 2015;122(4):962970.

    • Search Google Scholar
    • Export Citation
  • 28

    Hayek LJ, Emerson JM, Gardner AMN. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp Infect. 1987;10(2):165172.

    • Search Google Scholar
    • Export Citation
  • 29

    Ayliffe GAJ, Noy MF, Babb JR, . A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection. J Hosp Infect. 1983;4(3):237244.

    • Search Google Scholar
    • Export Citation
  • 30

    Hekman KE, Michel E, Blay E Jr, . Evidence-based bundled quality improvement intervention for reducing surgical site infection in lower extremity vascular bypass procedures. J Am Coll Surg. 2019;228(1):4453.

    • Search Google Scholar
    • Export Citation
  • 31

    Prabhu AS, Krpata DM, Phillips S, . Preoperative chlorhexidine gluconate use can increase risk for surgical site infections after ventral hernia repair. J Am Coll Surg. 2017;224(3):334340.

    • Search Google Scholar
    • Export Citation
  • 32

    Kestle JRW, Riva-Cambrin J, Wellons JC III, . A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr. 2011;8(1):2229.

    • Search Google Scholar
    • Export Citation
  • 33

    Gupta A, Nair RR, Moorthy RK, Rajshekhar V. Effect of staphylococcal decolonization regimen and change in antibiotic prophylaxis regimen on incidence of postcraniotomy aseptic meningitis. World Neurosurg. 2018;119:e534e540.

    • Search Google Scholar
    • Export Citation
  • 34

    Humphreys H, Becker K, Dohmen PM, . Staphylococcus aureus and surgical site infections: benefits of screening and decolonization before surgery. J Hosp Infect. 2016;94(3):295304.

    • Search Google Scholar
    • Export Citation
  • 35

    Lefebvre J, Buffet-Bataillon S, Henaux PL, . Staphylococcus aureus screening and decolonization reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery. J Hosp Infect. 2017;95(2):144147.

    • Search Google Scholar
    • Export Citation
  • 36

    Shuman AG, Shuman EK, Hauff SJ, . Preoperative topical antimicrobial decolonization in head and neck surgery. Laryngoscope. 2012;122(11):24542460.

    • Search Google Scholar
    • Export Citation
  • 37

    Chan AK, Bisson EF, Fu KM, . Sexual dysfunction: prevalence and prognosis in patients operated for degenerative lumbar spondylolisthesis. Neurosurgery. 2020;87(2):200210.

    • Search Google Scholar
    • Export Citation
  • 38

    Guzel A, Ozekinci T, Ozkan U, . Evaluation of the skin flora after chlorhexidine and povidone-iodine preparation in neurosurgical practice. Surg Neurol. 2009;71(2):207210.

    • Search Google Scholar
    • Export Citation
  • 39

    Patel KS, Goldenberg B, Schwartz TH. Betadine irrigation and post-craniotomy wound infection. Clin Neurol Neurosurg. 2014;118:4952.

  • 40

    Chan AK, Mummaneni PV. In Reply: Chlorhexidine showers are associated with a reduction in surgical site infection following spine surgery: an analysis of 4266 consecutive surgeries. Neurosurgery. 2020;86(6):E581E582.

    • Search Google Scholar
    • Export Citation
  • 41

    Chen Y, Zhang L, Qin T, . Evaluation of neurosurgical implant infection rates and associated pathogens: evidence from 1118 postoperative infections. Neurosurg Focus. 2019;47(2):E6.

    • Search Google Scholar
    • Export Citation
  • 42

    Ho AL, Cannon JGD, Mohole J, . Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience. J Neurosurg Pediatr. 2018;22(6):710715.

    • Search Google Scholar
    • Export Citation
  • 43

    Haines SJ. Randomized clinical trials in the evaluation of surgical innovation. J Neurosurg. 1979;51(1):511.

  • 44

    Grady D, Parks M. Why is nonadherence to cancer screening associated with increased mortality?. JAMA Intern Med. 2019;179(2):143144.

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