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Subject Code : NURS2006
Assignment Task

Skin preparation post C-section

An evidence summary

This document summarises current evidence on different skin preparations to prevent infection, with implications for future research.

Why change is needed

Caesarean section is an increasingly common major surgical procedure performed on women worldwide and Australia has a higher rate of caesarean section (32% versus 28% of live births) compared to other Organisation for Economic Co-operation and Development (OECD)countries ( Betran et al. 2016).

Surgical site infections are the third most frequently reported hospital?acquired infections and women who give birth by caesarean section are 10 times at risk as they are exposed to both endogenous and exogenous source of infection during delivery. Integral to the prevention of surgical site infection is the adherence to aseptic techniques, one of which is the preoperative preparation of the operative site. Proper preparation of an incision site involves removing surface dirt and oil with a soap or detergent scrub plus applying a topical antimicrobial agent that will reduce the bacterial population to a minimal level. There are several skin preparation modalities that are approved by the Food and Drug Administration and are in use in operating rooms of health care organisations. Iodine or Iodophore (on its own or as an alcohol?containing agent) and chlorhexidine gluconate are the primary skin disinfectants that are seen in Australian Hospitals. Iodophore is effective against bacteria, fungi, viruses and spore?forming bacteria, and its disinfecting effect lasts for a long time. However, it cannot be used on mucous membranes and does not have an immediate antiseptic effect. Chlorhexidine gluconate is characterised by its immediate antiseptic effect, although it cannot kill the spores (Johansson 2007).

The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however, it is unclear whether preoperative skin antisepsis actually reduces postoperative wound infection, and, if so, which antiseptic is most effective. Therefore, this review will compare the effect of chlorhexidine gluconate to Iodophore on preoperative skin preparation for preventing post caesarean infection.

Review question(s)

Does pre-operative skin preparation using chlorhexidine gluconate compared to povidone-iodine influence the risk of developing surgical site infection post caesarean sections?

Methods
This evidence summaries use the best available evidence of intervention effectiveness identified from PubMed only

Inclusion.JPG

Search strategy
An initial search conducted in CINAHL resulted 0 studies hence the search was repeated in PubMed on 25th August 2020 using the following search string. 

1. emergency cesarean section OR elective cesarean section OR planned C-section
2. chlorhexidine gluconate OR Chlorhexidine Gluconate 4% Solution OR Avagard
3. Iodophore OR Iodine OR povidone-iodine
4. Surgical site infection OR Post-operative infection OR incision site

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Results
One meta-analysis, three RCTs, one retrospective study and one observational study were the mainsources of evidence for this evidence summary. No economic evaluations were found.

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Aworinde.JPG

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The evidence

This review is based on the studies that was identified during a PubMed search. Six studies (6745 women) contributed data to this review. The studies ranged from 2013-2020. Settings: The studies were conducted in Tel Aviv, Saudi Arabia, China, USA, Indonesia, (Fahmi 2017), Nigeria (Aworinde 2016). Of the included studies two were single-centre trials (Aworinde 2016, Kunkle 2015), one conduced in multi centres (Fahmi 2017); one retrospective study AmerAlshiek (2013).

Participants: In Aworinde (2016), women who had elective caesarean section with no overt risk for surgical site infections were included in this trial. While Kunkle (2014) recruited women aged 18 to 45 years undergoing scheduled caesarean delivery at 36 gestational weeks or greater. Fahmi (2017) included all women undergoing scheduled caesarean section in their trials. Participants in AmerAlshiek (2013) were women undergoing elective and non-elective C-Sections. The included studies were broadly methodologically sound but raised some specific concerns regarding risk of bias in a number of cases.

Intervention and Comparison: All the studies compared Chlorhexidine–alcohol versus povidone– iodine among pregnant women who underwent planned or emergency C-sections. Four studies compared preoperative application of chlorhexidine gluconate (2% chlorhexidine gluconate with 70% isopropyl alcohol) versus povidone iodine 10%.

The evidence collected for this summary has been grouped (below) under headings according to the focus of the outcomes.

Surgical site infection

Five out of the six studies suggested that chlorhexidine gluconate before C-Section, when compared with povidone iodine, may make little or no difference to the incidence of surgical site infection. However, surgical site infection appeared to be slightly reduced for women for whom chlorhexidine gluconate was used compared with povidone iodine. Surgical site infection was assessed from delivery to 30 days postoperative in Aworinde (2016), at three days and two weeks in Kunkle 2014; and seven days postoperative in Fahmi (2017); one week and one month in Elshamy (2020).

Prevalence of positive bacterial cultures

One small study (60 women) reported reduced bacterial growth at 18 hours after C-Section for women who had chlorhexidine gluconate preparation compared with women who had povidone iodine preparation (Kunkle (2015).

Reduce length of hospital stays and a reduction in repeat ER visits.

A retrospective study conducted by Amer-Alshiek (2013) among 326 women who had elective and non-elective C-Section identified antisepsis with chlorhexidine and alcohol was associated with a lower rate of SSIs, 10.43% versus 3.07% with povidone-iodine. This study also identified that use of chlorohexidine reduced the length of hospital stay and a reduction in repeat ER visits.

Suitable antiseptic agents

All the studies concluded that both chlorhexidine–alcohol and povidone–iodine are suitable antiseptic agents for skin preparation before elective C-section.

Research gaps

There is a need for more rigorous studies for use in evaluating the effectiveness of interventions to reduce surgical site infection. This field needs high quality, well designed RCTs, with larger sample sizes. High priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), and application methods (scrubbing, swabbing, or draping). The following gaps has been identified:

Length of outcome measured.

• Further research is recommended to identify whether the time of outcome assessment performed has any impact on the SSI rate
Impact on length of stay and readmissions
• There is a need for good quality studies that specifically explore the impact of chlorhexidine on the length of stay and readmission 

Duration of skin preparation
• Further research is recommended to identify whether the duration of skin preparation has any impact on the SSI rate
 

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  • Posted on : September 08th, 2018

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