Does preoperative skin cleansing at home prior to orthopaedic surgery have a role in the reduction of subsequent surgical site infection / periprosthetic joint infection ( SSI / PJI ) ?

As noted by the Centers for Disease Control and Prevention, preoperative skin cleansing with an antiseptic agent can substantially decrease skin microbial counts [1,2]. Studies examining this practice and its role in the reduction of SSI and PJI rates have produced conflicting findings. To determine the utility of preoperative skin cleansing in preventing SSIs/PJIs, the effectiveness and logistics of the practice must be taken into account. Preoperative skin cleansing can be executed using a variety of agents. Garibaldi et al. performed a prospective trial on over 700 patients and found rates of positive intraoperative wound cultures to be 4% for patients who showered and scrubbed with CHG, 9% for those who used povidone-iodine, and 14% for those who used medicated soap and water [3]. Several other published studies supported a connection between preoperative skin shower and CHG with decreasing overall culture rates [4–8]. Chlorhexidine bathing at home prior to surgery involves the use of either a 4% solution or a 2% cloth for a varying number of days based on the literature. Low-level evidence recommends the use of CHG cloths over bathing in its soap form [9]. Regardless of application methodology, CHG can either be bacteriostatic or bactericidal based on the concentration used for cleansing and its efficacy has been known to improve with frequency and duration of use [5,10,11]. The applicability of the aforementioned findings to SSI/PJI prevention in patients undergoing orthopaedic surgery remains unclear due to contradictory findings in the literature. Kapadia et al. studied 3,717 patients who underwent primary or revision total knee arthroplasties. The group found that the use of a pre-admission chlorhexidine protocol was associated with a reduced relative risks of PJIs after total knee arthroplasty (TKA), when compared to patients who did not receive a CHG protocol (0.3% vs. 1.9%; rate ratio (RR): 6.3, 95% confidence interval (CI) 1.9 to 20.1, p = 0.002) [12]. Similar results were seen even when the two patient cohorts were risk-stratified. A review of modern papers from 2009 to 2015 also showed a reduction in infection rates with preoperative chlorhexidine preparation [13]. A systematic review by Webster et al. of over 10,000 patients in the Cochrane Database also concluded chlorhexidine washes were better than not bathing at all. However, the use of chlorhexidine washes did not seem to change infection rates [11]. Nevertheless, the review reported a lower relative risk for SSIs in patients who used CHG compared to those who used placebo (RR: 0.91, 95% CI 0.8 to 1.40). Farber et al. reported on over 3,700 total joint cases with 1,891 using 2% cloth wipes at the surgical site one hour prior to their procedure [12]. They also found no differences in infection rates at the one-year follow-up for either group. As described above, the literature cannot affirm emphatically that skin cleansing at home prior to orthopaedic surgery has a role in reduction of subsequent SSIs or PJIs. There has yet to be any reports on the negative effects of preoperative skin cleansing at home prior to arthroplasty surgery and concerns for skin hypersensitivity associated with use of CHG are minor [4]. With really no downside and some potential upside (Table 1), it seems reasonable to consider some form of preoperative skin cleansing at home. Moreover, well-controlled trials are required to truly assess the efficacy of the preoperative skin baths. Initial cost data seems promising but may be institutionally-related with a potential net savings of $0.78 to $3.1 billion [14]. A true cost-assessment is necessary to understand if this low-risk means of infection prevention is cost-effective and whether it should be the standard of care prior to any orthopaedic/arthroplasty surgical procedure. In conclusion, Table 1 summarizes studies that have been completed regarding chlorhexidine preoperative bathing and its effects on SSIs/PJIs. The heterogeneity of skin cleansing regimens and varying compliance rates make it difficult to isolate preoperative preparation as the main determinant for infection prevention in patients undergoing orthopaedic surgery. Despite the data listed, it is important to understand that compliance is always a concern with this protocol as one study found 78% noncompliance despite focused pre-surgery education efforts [15].