SURGICAL INFECTIONS

Volume XX, Number X, 201X

ª Mary Ann Liebert, Inc.
DOI: 10.1089/sur.2015.033

The Combined Impact of Surgical Team Education

and Chlorhexidine 2% Alcohol on the Reduction
of Surgical Site Infection following Cardiac Surgery

Margaret M. Hannan, Katie E. O’Sullivan, Ann M. Higgins, Ann-Marie Murphy,

James McCarthy, Edmund Ryan, and John P. Hurley

Abstract

Background: The use of 2% chlorhexidine in 70% alcohol (CHG) has been associated with reduction in catheter-
related bloodstream infections and surgical site infection (SSI) in general surgery. Also, improved awareness of
best practice from the perspective of the operative team is likely to result in reductions in SSI rates.
Methods: This is an ambispective cohort study of patients undergoing elective cardiac surgery. Between
January 2010 and December 2010, patients underwent surgical preparation using Alcohol Povidone Iodine
(API). Between January 2011 and December 2011, the surgical team received education and switched to CHG
for surgical preparation. Univariate analysis was performed to identify the impact of known risk factors for SSI.
A logistic regression model was then fit to estimate the effect of education and CHG in the reduction of SSI in
2011, controlling for known SSI risk factors.
Results: There was a substantial reduction in overall SSI rate in 2011 following staff education and the
introduction of CHG. The overall unadjusted SSI rate was 4.67% versus 2.08% (p < 0.05) for 2010 and 2011
respectively. Using a logistic regression model, the combined effect of education and CHG in 2011 was a 63%
reduction in SSI in cardiothoracic surgery (OR 0.37, 95% CI: 0.17–0.83, p = 0.016), controlling for age, major
co-morbidities, and SSI risk factors.
Conclusions: Using CHG as pre-operative antiseptic in cardiothoracic surgery in a risk-adjusted cohort with
education of the surgical team is associated with significantly lower SSI infection rates when compared with API.
Emphasis must be placed on the multifactorial approach required to prevent postoperative wound infections.

S urgical site infections (SSIs) following cardiotho-

racic surgery (CTS) can lead to substantial post-operative
morbidity and mortality as well as significant cost to heathcare
providers [1]. The most devastating infections in CTS are
deep-seated sternal wound infections and mediastinitis. Pre-
vious studies have described a number of patient-related risk
factors for SSI in cardiothoracic surgery with the most com-
mon pathogens being Staphylococcus aureus and coagulase-
negative staphylococcus, components of skin flora [2–4]. The
incidence of SSI following cardiac surgery in previously
published studies is between 0.55 and 9.7% [2,4]. The National
Nosomial surveillance Network (NHSN) report rates of SSI
between 0.35–8.49% [5]. The most recent prevalence study of
SSI in European hospitals recorded an SSI rate of 3.3% for
cardiac surgery [6].
It is well recognized that certain interventions can and do
reduce the risk of SSI. These include avoiding hair removal at
the site, correctly timed antibiotic prophylaxis, pre-operative
skin disinfection and an interactive wound dressing applied
in theatre and left undisturbed for 48 h minimum [1–7,8].
Recent studies have demonstrated the benefits of chlorhex-
idine-based skin preparations in reducing bloodstream in-
fections, and the debate regarding the most effective skin
disinfectant is ongoing [9]. To date, neither the U.S. Centers
for Disease Control and Prevention (CDC) or the World
Health Organization (WHO) have suggested the optimum
antiseptic with which to prevent post-operative SSIs. The
CDC do, however, recommend a minimum of 0.5% chlor-
hexidine skin preparation with 70% alcohol for cleaning and
disinfecting the site of insertion of vascular catheters [2].
Several studies comparing alcoholic povidone iodine (API)
with 2% chlorhexidine in 70% alcohol (CHG) have been
published. The most notable of these, by Darouiche et al.,
demonstrated a substantial decrease in SSI with CHG over PI

Mater Private Hospital, Dublin, Ireland.

1
2 HANNAN ET AL.
using a single use sponge application system (Chloraprep) in
general surgery [6]. A systematic review of research compar-
ing CHG with API carried out in 2012 by Kamel et al. found
that although quite a number of studies had been conducted, the
concentration of chlorhexidine varied from study to study and
the API (includes both alcoholic and non-alcoholic API in
these studies and at different concentration) was sometimes
combined with alcohol and other times with water [11]. Au-
thors concluded that there is a lack of large well conducted
randomized controlled trials to prove unequivocally the
effectiveness of one antiseptic preparation over another [11].
The purpose of this study was to assess the combined
efficacy of staff education and changing from API to CHG in
reducing the incidence of SSI in cardiothoracic surgery over a
2-y period with prospective data collection.
Patients and Methods
The study was performed in a single tertiary referral centre
for cardiothoracic surgery (CTS). The 2-y study period was
from January 2010 through to December 2011. All patients
having CABG, valve or combination CABG and valve surgery
were prospectively enrolled in the study including those un-
dergoing re-do cardiac surgery. Patients undergoing CTS other
than those mentioned above were excluded. All patients’
baseline characteristics were prospectively recorded on a
proforma admission document and entered into an electronic
database for data analysis. CTS morbidity and mortality risk
factors were assessed using parameters assessed to compute
the EuroSCORE a European system for cardiac operative risk
evaluation [12]. Risk factors for infection were documented at
the time of admission and using the National Nosocomial In-
fection Surveillance (NNIS) the US system for assessing risk
factors for SSI.
The study was divided into two separate time periods. The
first ( January 1, 2010 to December 31, 2010) enrolled pa-
tients undergoing surgical preparation using API. No inter-
vention in terms of team education was performed during this
period. The second period ( January 1, 2011, to December 31,
2011) involved the introduction of two interventions; a 2-mo
education and training period, during which the surgical team
attended sessions on the optimum surgical preparation tech-
nique and a switch to CHG for surgical pre-operative an-
aesthetic. Detail with regard to the pre-operative preparation
is outlined, there was no alteration to this or to post-operative
management during the study period.
Pre-operative preparation
All patients underwent the same pre-operative investigation
and theatre preparation for cardiac surgery. Surgical antibiotic
prophylaxis was vancomycin 1 gram BD and gentamicin 5mg/
kg OD for 24 h. This was administered at induction of anaes-
thesia prior to surgical checklist completion [13]. Pre-operative
skin preparation was three chlorhexidine 4% aqueous solution
showers pre-operatively. These were timed as follows: The day
before surgery, the evening before surgery and the morning of
surgery. Prior to showering the patient was instructed to use
chlorhexidine 4% aqueous solution to scrub chest (from chin to
umbilicus), arms, and legs using a clean sterile dressing pad for
each shower. The patient then dressed in his/her theatre gown or
fresh nightwear. As near as possible to the time of surgery, male
patients had leg, arm, and chest hair clipped where necessary by
a porter. Female patients had leg hair clipped where necessary
[10]. Where patient was unable to shower because of clinical
limitations such as unstable angina, a healthcare worker applied
chlorhexidine 4% aqueous solution to the chest (chin to umbi-
licus), arms, and legs using sterile pads. This was then allowed
to dry on the skin. This process remained constant throughout
the study period. Patients with a known history of diabetes
mellitus or noted to by hyperglycaemic based on fasting glucose
concentrations or HbA1c concentrations preoperatively were
reviewed by a consultant endocrinologist and placed on an ap-
propriate regimen to ensure pre-operative normoglycaemia.
Surgical technique
There was no change in cardiac surgeons or cardiac surgical
fellows during this 2-y period. An educational session for the
surgical team regarding the implementation of the change in
surgical preparation was undertaken at the time of the change
to CHG in 2011. This involved weekly teaching sessions
conducted by the infection control nurse (A.H.) and involved
an outline of the optimum painting and draping techniques
using CHG over a 2-mo period. Meticulous attention to detail
was emphasized to the surgical fellows.
Following the induction of anesthesia, the patient was
positioned and API (2010) or CHG (2011) applied to the
anterior neck, chest, abdomen, groin, and circumferentially
around the lower limbs including feet. In the case of API, this
was applied using sterile sponges, which were discarded
frequently and when moving to an unpainted area of skin. All
painted areas were allowed to dry fully. Two percent chlor-
hexidine gluconate and 70% isopropyl alcohol (Chlorprep)
was applied using pre-impregnated sponges supplied by
manufacturer and allowed to dry completely for a minimum
of 3 min. Sterile surgical drapes were placed under the pa-
tients’ legs while they were elevated by an assistant grasping
the ankles with a sterile pad. Adhesive strips were placed
along the lateral abdomen and thorax. In the case of a radial
graft harvest for coronary artery bypass grafting, the chosen
arm was painted also and laid on top of a sterile drape cov-
ering an armboard. For cases where a radial harvest was not
required, both arms were fully covered from the shoulder and
placed adjacent to the patient’s thorax. An integrated genital
cover was applied on top of a sterile towel and sealed with an
adhesive strip horizontally just above the level of the umbi-
licus. When the posterior aspect of the lower limbs was fully
painted, foot covers were applied in a sterile fashion and the
legs lowered to the barrier drape overlying the operating ta-
ble. A separate thoracic drape was applied with a clear
window extending from above the supraclavicular notch to
below the xiphisternum. The clear adhesive film was securely
applied to the skin and the remaining part of the drape was
unfolded both laterally and toward the head and feet. The
upper segment was secured vertically to create a barrier
separating the upper part of the table from the operative field.
In CABG, the long saphenous vein was exposed using a
continuous longitudinal incision. No endoscopic vein harvests
were performed. The adventitial layer was stripped and side
branches ligated using ligaclips. Tissue was closed in layers
using 2-0 vicryl and skin was closed using 3-0 monocryl
monofilament. Skin was cleaned with a 0.5% Chlorhexidine
with 70% denatured ethanol soaked swab solution and a sterile
mepore dressing was applied to the length of the surgical
SURGICAL TEAM EDUCATION AND 2% CHLORHEXIDINE IN 70% ALCOHOL ON REDUCTION OF SSI 3

incision. Median sternotomy was carried out in the standard
fashion from just below the sternal notch to the tip of the xi-
phoid process using a scalpel and electrocautery for pinpoint
haemostasis. Electrocautery was used to divide the pectoral
fascia and a sternal saw used to divide the sternum in the
midline. Once the sternum was split, the two edges were re-
tracted and bleeding from the sternal edge controlled with
electrocautery and bone wax.
Where internal mammary artery harvest was undertaken,
the left internal mammary artery (LIMA) was used and har-
vested in a pedicled fashion. No patient underwent bilateral
internal mammary artery (BIMA) harvest. Cardiopulmonary
bypass was instituted allowing CABG, valve replacement
or CABG with concomitant valve replacement to proceed.
All cases were performed using cardiopulmonary bypass. A
combination of single and double Myo wires was used to
reunite the sternum; three single wires in the manubrium,
three Myo wires around the body of the sternum, and one to
two single wires at the lower portion of the sternum de-
pending on sternal length. The wound was closed in three
layers; two deep layers with 1-0 Prolene and 3-0 Monocryl
for skin closure. The wound was cleaned using a 0.5%
Chlorhexidine with 70% denatured ethanol soaked swab and
a sterile mepore dressing applied to the length of the incision.
All dressings remained unchanged for 5 d except in emer-
gency, and all patients were nursed on the same cardiotho-
racic ward following discharge from the intensive care unit
and until discharge home. A tight glycemic control protocol
was adhered to in the post-operative period using an intra-
venous insulin infusion in the intensive care unit (ICU). Any
patient with a history of diabetes mellitus or evidence of
newly diagnosed diabetes mellitus was transitioned from that
to the appropriate oral hypoglycemic agents or insulin by a
consultant endocrinologist.
Surgical Site Infection Surveillance
Surgical site surveillance had been established in the hospital
in 1995 and was carried out by the infection prevention and
control (IPC) team using a combination of laboratory based and
ward liaison surveillance, reported quarterly and annually.
There was no change to this process during the study period.
Regarding pre-study SSI rates, the overall incidence in 2009
was 3.8%, with a sternal wound rate and radial/saphenous graft

Table 1. Baseline Patient Characteristics, Type of Surgery, Surgical Site Infection Risk Factors,
and Operative Risk Factors Comparing the 2010 and 2011 Pre- and Post-intervention Cohorts
2010 2011 p
Patient number 364 480
Age, median (IQR) 68 ( 61, 75) 68 ( 61, 74) 0.2923
Female 65 ( 17.9%) 76 ( 15.3%) 0.4569
Male 299 ( 82.1%) 404 ( 84.1%)
Type of surgery
CABG 216 ( 59.3%) 265 ( 55.2%) 0.1285
CABG and valve surgery 37 ( 10.2%) 71 ( 14.8%)
Valve surgery 110 ( 30.2%) 144 ( 30.0%)
Surgical Site Infection risk factors
ASA score 1 1 ( 0.3%) 0 ( 0%) 0.0015
ASA score 2 110 ( 30.2%) 96 ( 20%)
ASA score 3 217 ( 59.6%) 319 ( 66.5%)
ASA score 4 36 ( 9.9%) 65 ( 13.5%)
Incision to closure (minutes), Median (IQR) 224 (196, 250) 223 (194, 256) 0.6982
Previous cardiac surgery 21 ( 5.8%) 19 ( 4.0%) 0.2531
Active infective endocarditis 3 ( 0.8%) 1 ( 0.2%) 0.3206
Body Mass Index, Median (IQR) 28 ( 25, 31) 28 ( 25, 31) 0.1414
Diabetes mellitus 52 ( 14.3%) 95 ( 19.8%) 0.0436
Previous smoker 189 ( 51.9%) 294 ( 61.3%) 0.0076
Operative risk factors
LVEF, Median (IQR) 50% ( 48%, 55%) 55% ( 50%, 59%) < .0.001
Creatinine (mg/dl), Median (IQR) 1.1 ( 0.93, 1.33) 1.27 ( 1.09, 1.48) 0.0001
Urgent surgery 102 ( 28%) 90 ( 18.8%) 0.0016
Previous MI 64 ( 17.6%) 143 ( 29.8%) 0.0001
Pre-operative hemodynamic instability 3 ( 0.8%) 1 ( 0.2%) 0.3206
Family history of heart disease 168 ( 46.2%) 177 ( 36.9%) 0.0072
Renal failure 9 ( 2.5%) 28 ( 5.8%) 0.0179
Asthma 3 ( 0.8%) 40 ( 8.3%) < 0.0001
Pulmonary disease 3 ( 0.8%) 36 ( 7.5%) < 0.0001
Cerebrovascular disease 27 ( 7.4%) 15 ( 3.1%) 0.0061
Hepatic disease 28 ( 7.7%) 9 ( 1.9%) 0.0001
Carotid disease 22 ( 6.0%) 5 ( 1.0%) < 0.0001
In-hospital mortality 5 ( 1.4%) 6 ( 1.3%) NS
IQR = interquartile range; CABG = coronary artery bypass surgery; SSI = surgical site infection; ASA = American Society of
Anesthesiology; LVEF = left ventricle ejection fraction; MI = myocardial infarction; NS = not significant.
4 HANNAN ET AL.

infection rate of 2.45% (n = 10) and 2% (n = 8) respectively. All
CTS patients were reviewed in outpatient clinics by their op-
erating surgeon approximately 6 wks post-surgery and any late
infections were recorded at that time. Any patient re-admitted
within 12 mo of their surgery (in the case of valve surgery)
with infection were also included. The CDC definitions of SSI
were used to define infections and all infections confirmed
by the IPC Nurse and IPC doctor in consultation with the sur-
gical team.
Statistical Analysis
A univariate analysis was conducted on patient baseline
characteristics as well as associated SSI rate between January
2010 and December 2011. Pearson chi squared test was uti-
lized for dichotomous variables and Wilcoxon signed-rank test
for continuous variables. A logistic regression model was then
fit to estimate the effect of CHG in the reduction of SSI in 2011,
controlling for age, major co-morbidities (e.g., left ventricular
ejection fraction (LVEF), history of acute myocardial infarc-
tion (MI), elevated creatinine, and diabetes mellitus), body
mass index (BMI), and other known SSI risk factors, for ex-
ample, Anesthetic Surgical Assessment (ASA) score, presence
of active infection at the surgical site, and duration of surgery.
Results
Patient characteristics
A total of 844 patients were enrolled in the study; 364 were
enrolled in the 2010 pre-intervention cohort and 480 in the
2011 post-intervention cohort. There was no substantial dif-
ference in baseline patient characteristics identified between
the two cohorts (Table 1). The median (inter-quartile range)
age was 68 (61 to 75 y) y versus 68 (61 to 74 y) y for patients
in the pre-intervention versus post intervention cohort, re-
spectively (p = 0.29).

Table 2. Summary of Overall Patient Operative risk factors

Characteristics, Risk Factors for SSI Patients in the pre-intervention 2010 cohort had a higher
and Associated SSI Rate
frequency of urgent versus elective surgery (28 vs. 18.8%
Surgical Site p = 0.0016), a higher family history of heart disease (46.2 vs.
Patients Infections 36.9% p = 0.0072), incidence of cerebrovascular (7.4 vs. 3.1%
p = 0.0061), carotid (6 vs. 1% p < 0.0001) and hepatic disease
Risk (7.7 vs. 1.9% p = 0.0001). Patients in the post-intervention
factors n % n % p 2011 cohort had a higher incidence of major co-morbidities
Age such as previous myocardial infarction (29.8 vs. 17.6%
£ 74 641 76.0% 18 2.8% 0.26 p = 0.0001), pulmonary disease (7.5 vs. 0.8% p < 0.0001), and
> 74 203 24.1% 9 4.4% asthma (8.3 vs. 0.8% p < 0.0001) and a higher incidence of
Baseline creatinine (mg/dl) renal failure at the time of surgery (5.8 vs. 0.8% p < 0.0001).
£ 1.49 664 78.7% 21 3.2% 0.81 There was no difference in in-hospital mortality rates between
> 1.49 180 21.3% 6 3.3% the two groups (1.3 vs. 1.4% NS).
Previous MI
No 637 75.5% 23 3.6% 0.36 Surgical site infection risk factors
Yes 207 24.5% 4 1.9% Univariate analysis of risk factors for surgical site infec-
Diabetes mellitus tion failed to reveal any statistically significant correlation
No 697 82.6% 19 2.7% 0.12 with the incidence of SSI. Specifically, there was no associ-
Yes 147 17.4% 8 5.4% ation between age (p = 0.26), baseline creatinine (p = 0.81),
LVEF previous MI (p = 0.36), diabetes mellitus (p = 0.12), reduced
< 25% 830 98.3% 26 3.1% 0.37 LVEF (p = 0.37), ASA grade (p = 0.65), incision to closure
‡ 25% 14 1.7% 1 7.1% time (p = 0.37), or BMI (p = 0.68) and the occurrence of SSI
ASA class identified (Table 2).
1–2 207 24.5% 5 2.4% 0.65
3–4 637 75.5% 22 3.5%
Incision to closure time Table 3. Comparison of Site and Depth
£ 250 min 631 74.8% 18 2.9% 0.37 Specific Surgical Site Infection Incidence
> 250 min 213 25.2% 9 4.2% between 2010 and 2011
BMI
£ 30 587 69.6% 20 3.4% 0.68 2010 2011
> 30 257 30.5% 7 2.7% n = 364 % n = 480 % p
Major co-morbidity (creatinine >1.49, LVEF <25%, All incision site 17 4.67 10 2.08 0.0468
previous MI or diabetes mellitus) infection
No 442 52.4% 13 2.9% 0.7 Infection site
Yes 402 47.6% 14 3.5% Graft site 10 2.75 1 0.21 0.001
Major SSI risk (ASA > 2, incision to closure Femoral vessel 1 0.27 2 0.42 NS
time > 250 min, or BMI > 30) exposure
No 127 15.1% 1 0.8% 0.11 Sternum 6 1.65 7 1.46 NS
Yes 717 85.0% 26 3.6% Infection depth
Superficial infection 13 3.57 7 1.46 0.046
MI = myocardial infarction; LVEF = left ventricle ejection fraction; Deep infection 4 1.1 3 0.63 NS
ASA = American Society of Anesthesiology; BMI = body mass index.
SURGICAL TEAM EDUCATION AND 2% CHLORHEXIDINE IN 70% ALCOHOL ON REDUCTION OF SSI 5

Table 4. Factors Associated With an Increased Multivariable adjusted effect of 2% Chlorhexidine

Risk of SSI with alcohol and education on SSI rates

Odds ratio Using multivariable adjusted rates the estimated effect of

(95% CI) p CHG and education in reduction of SSI in 2011 was 63%
(OR: 0.37, 95% CI: 0.17–0.83, p = 0.016) compared with API
Year 2011 0.37 (0.17, 0.83) 0.0159 in 2010, controlling for age, major co-morbidities, and
Age > 74 y 1.52 (0.67, 3.47) 0.3181 known SSI risk factors (Table 4). An outline of the specific
Present of major co-morbidity* 1.20 (0.55, 2.62) 0.6421 microorganisms isolated from respective wound sites is de-
Present of major SSI risks** 5.86 (0.78, 44.07) 0.0859
tailed (Table 5).
Figures calculated using multivariate logistic regression.
ASA = American Society of Anesthesiology; LVEF = Left ventricle Discussion
ejection fraction; MI = Myocardial infarction; BMI = body mass
index; SSI = Surgical site incision. Surgical site infection in CTS contributes to significant
*Creatinine >1.49, LVEF <25%, MI history, or diabetes mellitus, morbidity and mortality post-operatively and the develop-
SSI; surgical site infection. ment of mediastinitis is a devastating complication of sternal
**ASA >2, incision to closure time >250 min, or BMI >30.
wound infection [14]. Recently, implementation of multi-
disciplinary prevention measures as a care bundle have been
Unadjusted SSI rates shown to reduce the incidence of deep sternal wound infec-
There was a substantial reduction in overall SSI rate in tions [15]. Such bundles encompass a multitude of measures
2011 following staff education and the introduction of CHG. at each point throughout the entire pre- to post-operative time
The overall unadjusted SSI rate was 4.67% versus 2.08% course of a patient’s stay and include screening for MRSA
(p < 0.05) for 2010 and 2011 respectively (Table 3). The most carriage, hair clipping, skin preparation, prophylactic anti-
noticeable reduction in SSI was in the graft site 2.75% versus biotics, post-operative glycemic control, and appropriate
0.21%, (p < 0.03) for the year 2010 and 2011 respectively. wound dressings [15]. Regular audit and ongoing assessment
Likewise, the most noticeable reduction in terms of the of clinical practice is crucial and must be performed in a
classification of infection was from in superficial infection multi-disciplinary fashion as part of any successful Infection
rate from 3.57% versus 1.46% (p < 0.1) for the year of 2010 Prevention and Control (IPC) program [16].
and 2011 respectively. Our study demonstrated a statistically significant reduction
in SSI rates for graft sites from 2.75% in our 2010 cohort, to
0.21% in our 2011 cohort. These were associated with a
Table 5. Organisms Isolated From Site-specific substantial decrease overall in the numbers of patients clas-
Surgical Site Infections sified as superficial SSI infection from 3.57% in 2010 to
Organism Number 1.46% in 2011. The major difference between the two cohorts
was the reduction in graft infection, many of which were
Sternum caused by gram-negative microorganisms in 2010. There was
Superficial Staphylococus epidermidis 8 no substantial change in the number of deep SSI in the two
Proteus mirabilis 2 cohorts with two deep sternal wound infection identified in
Deep Escherichia coli 1 each cohort. Of note there were no cases of organ space
Staphylococus epidermidis 1 infection or mediastinitis in either cohort.
Pseudomonas proteus 1 Other infection control strategies investigated in cardiac
Methicillin-sensitive 1 surgery in recent years include the use of microbial sealants
Staphylococcus aureus to immobilize antimicrobials missed by skin prep. To date,
Donor Site one study failed to demonstrate successful decline in SSI
Superficial Escherichia coli 1 incidence resultant from their use [17]. However, a number of
Methicillin-sensitive 1
Staphylococcus aureus authors report to the contrary; Iyer et al. performed a ran-
Proteus mirabilis 1 domized trial of Integuseal (Halyard, Alpharetta, Georgia),
Proteus mirabilis & 3 demonstrating a 2.1 versus 25.5% incidence of donor site
Staphylococcus epidermidis infections when compared with conventionally prepared skin
Methicillin-resistant 1 [18]. Similar results were obtained by Dohmen et al. although
Staphylococcus aureus their study was conducted in a non-randomized fashion [19].
Klebsiella 1 A total of 280 patients underwent standard skin preparation
Enterobacter cloacae 1 with 300 allocated to the microbial skin sealant group. The
Deep Escherichia coli 1 incidence of surgical site infection was lower in the sealant
Enterobacter faecalis serratia 1 group (2.3 vs. 6.8% p = 0.011). Interestingly, Falk-Brynhildsen
liquefaciens, E. coli et al. investigated further and noted that at the time of surgery
Femoral Cut Down patients in whom a skin sealant was used had almost no in-
Superficial Pseudomonas species 1 traoperative bacterial presence on the skin, whereas a relatively
Methicillin-sensitive 1
Staphylococcus aureus high incidence of late wound infection developed, suggesting
Escherichia coli 1 that the wound contamination occurred post-operatively [20].
One additional strategy has been the use of topical vancomycin
Deep Proteus mirabilis, Pseudomonas 1
and Anaerobe and Lazar et al. demonstrate a reduction in superficial sternal
6 HANNAN ET AL.
wounds in patients receiving topical vancomycin in addition to
tight glycemic control [21].
When the risk factors for the two cohort groups were
compared, most of the baseline characteristics such as BMI,
age, incision to closure time, gender, and previous cardiac
operations were similar. However, on univariate analysis
there were substantial differences in some clinical charac-
teristics between the 2010 and 2011 cohorts. Interestingly, in
the post-intervention group, the patients had higher ASA
scores and higher incidence of diabetes mellitus, both of
which are well recognized as increasing infection risk. This
finding of substantially lower infection rates despite sub-
stantially higher risk factor for in the 2011 cohort adds further
strength to the conclusions of this paper that the use of CHG
and a period of education is a crucial intervention. It has been
shown that education has a positive effect on retention of
knowledge, attitudes and practices of staff with respect to
hospital infection control measures [22]. Undoubtedly, fo-
cused education of registrars and fellows in skin preparation
technique and drying time resulted in more attention to detail
with regard to the process in 2011 versus 2010 [22]. How-
ever, many studies have indicated that education alone will
not create sustained improvement [23]. Organisms cultured
from sternal and donor site infections are in keeping with
those reported by other series [24]. It should be noted that
methicillin-resistant Staphylococcus aureus was cultured
from three superficial donor site infections.
This study does have a number of limitations. This is a cohort
study rather than a blinded, randomized study, which is a rec-
ognized limitation. Additionally, our data is gathered from a
single center. Recent evidence suggests that there is substantial
center-level variation in the incidence of infection rates fol-
lowing cardiac surgery with as much as 18.2% variability
identified between centers, not explained by individual patient
characteristics [25]. Thus, ideally our intervention would be
tested in multiple centers and the effect assessed. It is not
possible based on this study’s design to segregate the benefit
obtained from each element of the study; in other words, what
impact education compared with the change in agent made the
outcome results. Since completion of this study, we have further
revised our institutional policy and now weight-dose prophy-
lactic vancomycin administered pre-operatively, which was not
our practice at the time of this study.
Conclusion
This study demonstrates combined effect of CHG surgical
skin preparation and education on the reduction in SSI rates
following cardiac surgery. The next logical step of investiga-
tion is to repeat this study in a multi-center study to assess
reproducibility of the interventions and to do so in a fully
randomized fashion. We have demonstrated the importance of
a multi-factorial approach required to prevent post-operative
wound infections.
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Address correspondence to:
Ms. Katie E. O’Sullivan
Mater Private Hospital
Eccles St.
Dublin 7
Ireland
E-mail: kaosulli@tcd.ie