Antisepsis versus antimicrobial chemotherapy and indications for eye antisepsis.
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Anti-Bacterial Agents↗
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[Clinical evaluation of the ocular safety of Amukine 0.06% solution for local application versus povidone iodine (Bétadine) 5% solution for ocular irrigation) in preoperative antisepsis].
INTRODUCTION: The aim of this monocentric, randomized, comparative, open study was to evaluate the safety of Amukine 0.06% solution (an isotonic hypochloride sodium solution) versus a 5% povidone iodine solution (Bétadine 5% solution for ocular irrigation) in antisepsis before cataract surgery. MATERIAL AND METHODS: One hundred and thirteen patients, aged between 49 and 90 years, were included and split, after randomization, into two groups: one testing Amukine 0.06%, the other testing a 5% povidone iodine solution. For each group, after local anesthesia, the antiseptic procedure consisted of an antisepsis of periocular teguments followed by an eye antisepsis through the instillation of two drops of the tested product in the conjunctival fornices. The safety evaluation was performed by grading superficial punctate keratitis 24 hours after surgery (slit lamp examination after fluorescein instillation). Conjunctival hyperemia scores by examination of the bulbar conjunctiva before the first instillation, immediately before surgery, and 24 hours after surgery were also compared. RESULTS: One hundred and seven reports were analyzed. Concerning the presence of corneal superficial punctate keratitis 24 hours after surgery, mean scores were not different (0.27 for the Amukine 0.06% group and 0.38 for the povidone iodine group; p=0.27 Mann Whitney test). The observations did not show a different progression of conjunctival hyperemia depending on the treatment group (p=0.65 (immediately after application) and p=0.52 (after 24 hours); Mann Whitney test). CONCLUSION: In this study, the ocular safety of Amukine 0.06% solution was not different from a 5% povidone iodine solution. Therefore, Amukine 0.06% is a new interesting approach to surgical antisepsis in ophthalmology and an alternative in case of iodine allergy.
Aged↗
A comparison of the effect of chlorhexidine antisepsis, soap and antibiotics on bacteriuria, perineal colonization and environmental contamination in spinally injured patients.
The effect of chlorhexidine antisepsis on bacteriuria, perineal colonization by coliforms and environmental contamination by these organisms was investigated in spinally injured patients treated by intermittent catheterization. Patients were body washed daily in chlorhexidine and chlorhexidine cream was applied to the glans penis after each catheterization. Urine cultures were obtained each day. A statistically significant reduction in bacteriuria was achieved by antisepsis in male patients not receiving antibiotics, from 74% of urine cultures in patients receiving soap to 60% with antisepsis (P less than 0.01). No effect of antisepsis was found on perineal coliform colonization, nor on contamination of bed sheets or the environment by these organisms. There was a significant reduction in perineal coliforms by antibiotics.
Anti-Bacterial Agents↗
[Antisepsis and disinfection: the necessity of a conceptual demarcation].
Increasing international cooperation in the areas of research, teaching, trade and healthcare has called for standardization of the terminology. In disinfection and antisepsis such efforts have been pursued for almost 20 years but without great success. This contribution to the definition of antisepsis and its clear separation from disinfection is supposed to promote international discussion. German terms for skin, mucosa and wound antisepsis are proposed which permit to restrict the term disinfection to the application of antimicrobial measures to inanimate objects and surfaces.
Antisepsis↗
Comparison of local povidone-iodine antisepsis with parenteral antibacterial prophylaxis for prevention of infective complications of TURP: a prospective randomized controlled study.
OBJECTIVE: To determine whether antisepsis with povidone-iodine solution applied at the external urethral meatus confers protection against infective complications following transurethral resection of the prostate (TURP) and compare that with antibacterial prophylaxis. METHODS: A total of 167 patients with sterile urine undergoing TURP for benign prostatic hyperplasia (BPH) were prospectively randomized into three groups. Group A, had gauze soaked in saline applied at the urethral meatus (control group). In group B, the gauze was soaked in povidone-iodine instead of saline and group C had a single 1 g i.v. injection of cephradine at induction of anaesthesia with no treatment for the meatus. Bacteraemia, post-operative bacteriuria and other infective complications were compared in the three groups. Associations of bacteriuria at catheter removal and intra-operative bacteraemia with infective complications and with long term bacteriuria were also studied. RESULTS: Bacteriuria rate at catheter removal was not significantly different in the three groups. However, intraoperative bacteraemia and bacterial growth at the external urethral meatus was significantly lower in group C. Bacteriuria at catheter removal was significantly associated with bacterial growth at the meatus but not with long term bacteriuria at 3 months. Bacteriuria at catheter removal could not accurately predict infective complications. CONCLUSION: Post-TURP bacteriuria appears to be preceded by bacterial growth at the external urethral meatus. Antisepsis with povidone-iodine solution application at the meatus does not confer adequate protection against meatal bacterial growth as that obtained by prophylactic antibacterials. Nonetheless, neither antibacterial prophylaxis nor local antisepsis could reduce bacteriuria rate in this study.
Administration, Topical↗
Hand antisepsis: evaluation of a sprayer system for alcohol distribution.
OBJECTIVE: To evaluate the usefulness of a new alcohol sprayer by comparing it with an individual bottle of alcohol. Patterns of use and perceptions among healthcare personnel were compared for the two products. DESIGN: Observational study recording the volume of alcohol used and the compliance rate (frequency of hand antisepsis per number of opportunities), and a survey of healthcare workers' perceptions of the different hand hygiene strategies. SETTING: A 20-bed medical unit in a public hospital in Marseille, France. PARTICIPANTS: Healthcare workers of an infectious disease unit INTERVENTIONS: Hand hygiene alcohol systems (sprayer vs individual bottle, 70% ethyl alcohol). RESULTS: The sprayer was used more frequently than the individual bottle (12.6 vs 9.7 hand washes per day). With the sprayer system, compliance was 91% for physicians, 28% for nurses, and 8% for housekeeping personnel. Alcohol hand antisepsis was preferred to washing hands with soap and water in low-risk situations such as simple entrance into a room (91% vs 36%; P < 10(-6)) or simple contact with a patient (69% vs 40; P < .005). The sprayer system was considered easier to use (95%), more hygienic (90%), and faster (92%), with a better tolerance than the individual bottle. CONCLUSION: The new alcohol sprayer should improve rapid hand antisepsis.
Administration, Topical↗
Evaluation of skin antisepsis prior to blood culture in neonates.
In our Intensive Care Nursery, coagulase-negative staphylococcus is the most frequent blood culture isolate. As skin antisepsis is critical in preventing blood culture contamination, we examined the efficacy of the chlorhexidine tincture (CH) used in our nursery for this purpose. Staphylococcus epidermidis colonized the forearms of 88% of infants tested, in a mean density of 10(4) organisms/cm2. Following a 60-second application of CH (0.5% in 70% ethanol), bacterial growth from forearm skin remained abundant in 15/38 infants (39.4%). Cleansing with 70% isopropyl alcohol, followed by CH as above, left abundant residual growth in only 1/37 infants (2.7%) (P less than 0.001). All 136 S. epidermidis tested were susceptible to CH (MIC less than 5 micrograms/ml) and 14 of 15 exposed to CH 0.02% were rapidly killed (greater than or equal to 98% fall in viable counts within 90 sec). We conclude that two-phase antisepsis using isopropanol followed by CH is a more effective preparation for blood culture in neonates than is CH alone.
1-Propanol↗
Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel.
OBJECTIVE: To compare the frequency of skin irritation and dryness associated with using an alcoholic-hand-gel regimen for hand antisepsis versus using soap and water for hand washing. DESIGN: Prospective randomized trial with crossover design. Irritation and dryness of nurses' hands were evaluated by self-assessment and by visual assessment by a study nurse. Epidermal water content of the dorsal surface of nurses' hands was estimated by measuring electrical capacitance of the skin. SETTING: Miriam Hospital, a 200-bed university-affiliated teaching hospital. PARTICIPANTS: Thirty-two nurses working on three hospital wards participated in the trial, which lasted 6 weeks. RESULTS: Self-assessment scores of skin irritation and dryness decreased slightly during the 2 weeks when nurses used the alcoholic-hand-gel regimen (mean baseline score, 2.72; mean final score, 2.0; P=.08) but increased substantially during the 2 weeks when nurses used soap and water (mean baseline score, 2.0; mean final score, 4.8; P<.0001). Visual assessment scores by the study nurse of skin irritation and dryness did not change significantly when the alcoholic-hand-gel regimen was used (mean baseline and final scores were both 0.55), but scores increased substantially when nurses used soap and water (baseline score, 0.59; mean final score, 1.21; P=.05). Epidermal water content of the dorsal surface of nurses' hands changed little when the alcoholic-hand-gel regimen was used (mean+/-standard deviation baseline electrical capacitance reading, 24.8+/-6.8; mean final reading, 25.7+/-7.3), but decreased significantly (skin became dryer) with soap-and-water hand washing (mean baseline, 25.9+/-7.5; mean final reading, 20.5+/-5.4; P=.0003). CONCLUSIONS: Hand antisepsis with an alcoholic-hand-gel regimen was well tolerated and did not result in skin irritation and dryness of nurses' hands. In contrast, skin irritation and dryness increased significantly when nurses washed their hands with the unmedicated soap product available in the hospital. Newer alcoholic hand gels that are tolerated better than soap may be more acceptable to staff and may lead to improved hand-hygiene practices.
Antisepsis↗
Free-hand technique with ordinary antisepsis in abdominal US-guided fine-needle punctures: three-year experience.
PURPOSE: To evaluate the adequacy of ordinary antisepsis in ultrasound (US)-guided free-hand fine-needle puncture. MATERIALS AND METHODS: Diagnostic and therapeutic procedures (n = 573) were performed in 456 patients. No puncture attachments, sterile gloves, or drapes or covers were used. Before each procedure the transducer was cleaned with a solution of water and 70% alcohol. No needles were contaminated. Patients were monitored for 5 days to exclude sepsis. Subsequently, the patients underwent follow-up blood and laboratory testing, including testing for for hepatitis B and C markers and human immunodeficiency virus antibodies, every 3 months for 6 months. The operators underwent the same follow-up for the first 6 months and for an additional 6 months. RESULTS: No patient or operator presented with fever or sepsis or with negative viral or hepatitis markers that became positive during follow-up. CONCLUSION: Use of this free-hand US-guided technique with ordinary antisepsis is safe for patients and operators, and it allows savings in time and the cost of materials.
Abdomen↗
Innovations in health care: antisepsis as a case study.
An innovation often occurs in several arenas almost simultaneously, after being preceded by a long preparatory period when information and experience are accrued to the point at which opinion is influenced to change. Nevertheless, the introduction of an innovation is usually accompanied by resistance and hostility. This article traces the development of the concept and practice of antisepsis in health care, with emphasis on the contributions of three individuals who were contemporaries practicing in different health care fields, but who apparently were uninfluenced by each others' work. Semmelweis, a Hungarian obstetrician, recognized the importance of person-to-person transmission of infectious agents and effected dramatic reductions in puerperal mortality by requiring antiseptic handwashing. Lister, a Scottish surgeon, was the first physician to apply the germ theory to clinical practice and developed the techniques of antiseptic surgery and wound care, resulting in dramatic reductions in surgical mortality. Nightingale, a British nurse, initiated sanitary reforms in hospitals, schools, and military camps in England and abroad, incorporating high levels of environmental and personal hygiene. These reforms were also succeeded by dramatic reductions in mortality. In light of historical and current evidence of efficacy and the evidence of continued inadequacies in practice, it seems reasonable to speculate that further reductions in nosocomial infection rates are possible by a more careful application among individual practitioners of the basic principles of antisepsis.
Antisepsis↗
[Prevention of abscess of the abdominal wall by continuous antisepsis, combined with antibiotherapy. 4751 cases].
The reduced incidence of wall abscesses following routine general surgery was studied in 4751 cases over the period from 1973 to 1987. The therapeutical evolution spanned over three consecutive treatment periods, each one falling into one patient group. The reference period (Group I) extended from 1973 to 1978. Starting from 1978 and up till 1984 (Group 2), systematic repeated lavage of the operative field with an iodized polyvinylpyrrolidone solution were carried out, providing thus for true continuous antisepsis (CA). Starting from 1985 (Group 3), the method of continuous antisepsis was associated with systematic prophylactic antibiotherapy (SPAB). Groups 1, 2 and 3 included 2051, 1955 and 745 cases, respectively, and presented progressively decreasing rates of abscess formation (4%, 2.5%, 1.7%, respectively). In order to better assess these results, an in-depth analysis was carried out on two types of surgical operations, i.e., appendicitis and gynecological surgery, based on Altemeier's classification. The rate of abscess formation was lowered. This result is particularly interesting from the point of view of gynecological surgery, inasmuch as a relative increase in the frequency of the more esthetic horizontal incisions is being concurrently noted.
Abdominal Muscles↗
Genital antisepsis--test methodology and efficacy of povidone-iodine.
Indications for antiseptic prophylaxis include use prior to urinary catheterization and other transurethral instrumentations, diagnostic or therapeutic instrumentation of the cavum uteri, and operations on the external genitalia and the vagina. Indications for antiseptic therapy include treatment of wounds and of infections of the genital tract and also include treatment of the vaginas of pregnant women to prevent infection in the newborn. For prophylactic antisepsis the aim is the optimal reduction of potentially pathogenic microorganisms. In some fields of application, e.g. before urinary catheterization, an immediate effect on the mucous membrane is required, but on other occasions, such as transvaginal operations, an additional sustained effect is desired. Testing the efficacy of mucous membrane antiseptics, especially for the genital tract, necessitates the establishment of standardized test methods. The variability in vaginal flora at various ages makes it reasonable to study women aged 20-50 years. Studies presented in this paper indicate that microorganism sampling using a cotton swab moistened with neutralizing fluid can be favoured compared to using a rinsing technique and that anaerobic culture techniques enable the measurement of the high reduction factors achieved by very efficient antiseptic procedures. Test methods validated for hand disinfectants are used for calculations and statistical evaluation. The antimicrobial efficacy of six vaginal antiseptic procedures were compared in patients prior to vaginal surgery. Three minutes after treatment, the highest mean reduction (log RF) of the normal vaginal flora as well as of potentially pathogenic microorganisms was obtained by povidone-iodine solution undiluted and povidone-iodine solution 1:10 (log RF 3.60 and 2.68, respectively). Out of three detergents with antimicrobial efficacy, octenidine 0.1% was the most effective preparation (log RF 2.32). Chlorhexidine 0.1%, hexetidine 0.1% and chlorhexidine 0.05% led to lower reduction factors (log RF 1.80, 1.62 and 1.02, respectively). After 30 minutes the log reduction factors were approximating each other in nearly all procedures (log RF 2.79-3.25) except the log RF derived from the procedure performed using chlorhexidine 0.05% (log RF 2.07). Povidone-iodine solutions seem to be the method of choice for mucous membrane antisepsis where an immediate effect is required. If a long period of action is needed all procedures examined, except chlorhexidine 0.05%, are acceptable.
Adult↗
Prospective randomized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutaneous antisepsis for prevention of central venous catheter infection.
A multicenter prospective, randomized, controlled trial, with 0.5% tincture of chlorhexidene versus 10% povidone-iodine as cutaneous antisepsis for central venous catheter (CVC) insertion, was conducted for patients in intensive care units. Of 374 patients, 242 had a CVC inserted for >3 days and were used for the primary analysis. Outcomes included catheter-related bacteremia, significant catheter colonization (> or = 15 colony-forming units [cfu]), exit-site infection, serial quantitative exit-site culture (every 72 h), and molecular subtyping of all isolates. Patients in both study groups were comparable with respect to age, sex, underlying disease, length of hospitalization, reason for line insertion, and baseline APACHE II score. Documented catheter-related bacteremia rates were 4.6 cases per 1000 catheter-days in the chlorhexidine group (n=125) and 4.1 cases per 1000 catheter-days in the povidone-iodine group (n=117; not significant [NS]). Significant catheter-tip colonization occurred in 24 (27%) of 88 patients in the povidone-iodine group and in 31 (34%) of 92 patients in the chlorhexidine group (NS). A mean exit-site colony count of 5.9 x 10(5) cfu/mL per 25 cm(2) of the surface area of skin in the povidone-iodine group versus 3.1 x 10(5) cfu/mL per 25 cm(2) in the chlorhexidine group (NS) was found. There was a trend toward fewer exit-site infections in the chlorhexidine group (0 of 125 patients) versus those in the povidone-iodine group (4 of 117 patients; P=.053). Results of an intention-to-treat analysis were unchanged from the primary analysis. No difference was demonstrable between 0.5% tincture of chlorhexidine and 10% povidone-iodine when used for cutaneous antisepsis for CVC insertion in patients in the intensive care unit.
Adult↗
Meningococcemia as a model for testing the hypothesis of antisepsis therapies.
OBJECTIVE: To critically review the advantages and disadvantages of pediatric meningococcemia as a model for testing antisepsis therapies. DATA SOURCES: Research and review articles on the pathogenesis and treatment of human meningococcemia, as well as editorial commentaries discussing the failure of clinical trials for adult sepsis or Systemic Inflammatory Response Syndrome. Data from these sources are presented in the context of the author's experience as principal investigator in a large, randomized trial on children with invasive meningococcal disease. STUDY SELECTION AND DATA EXTRACTION: Studies were selected to include aspects of epidemiology, pathophysiology, outcome prediction, and therapeutic trials. DATA SYNTHESIS: Compared with an adult sepsis population, meningococcemia is a single disease, diagnosed clinically with high reliability. Patients are previously healthy, without underlying medical or surgical conditions. In contrast to sepsis trials, nearly all patients with meningococcal disease receive effective antibiotics. Finally, meningococcemia most closely resembles animal models of endotoxin infusion, in which most antisepsis therapies have been highly effective. However, the meningococcal model carries major disadvantages, among them that meningococcemia is rare and rapidly progressive and patients are widely dispersed geographically. In addition, a wide range of experimental therapies is routinely provided in an attempt to preserve life or limbs. CONCLUSIONS: Meningococcemia is an ideal model of a rapidly progressive bacterial infection associated with marked endotoxemia. Problems with the model can be overcome by extensive pretrial logistic planning, as well as close coordination and cooperation with national regulatory agencies.
Adult↗
Postmilking teat antisepsis.
An effort was made to present the historical development of postmilking teat sanitizers, to discuss advantages and limitations of postmilking teat sanitization relative to specific mastitis pathogens, regulatory requirements, and the generic types of teat sanitizers. Methodologies used to evaluate the potential of teat sanitizers in reducing incidence of new IMI were discussed. Efficacy data from numerous controlled studies were discussed briefly. Teat-dip manufacturers advertise differences in efficacy values that were obtained under controlled research conditions. We are led to believe that relatively small differences in efficacy should prompt the use of one product over another. These efficacy differences have little comparative value, because the products, in most instances, were studied independently and the commercial extrapolations leave much to be desired for factual purposes. Management practices on individual dairy farms have more effect on reduction of rate of infections than do small differences in product efficacy. Also, some companies advertise about effective, in vitro germicidal activity. Such data do not relate to reduction in rate of udder infections and should not be considered evidence of efficacy in prevention of mastitis. A startling realization should become evident from this review; a paucity of information is available on some vital parameters relative to prevention of IMI. Many important areas of mastitis control related to postmilking teat antisepsis need an increased research commitment. Some of these areas include: effects of temperature on germicidal activity of teat dips; effects of climatic conditions on teat microflora; epidemiology of IMI with environmental pathogens; relationship between teat skin condition and incidence of IMI; and alternative control methods to reduce incidence of IMI. This question is asked often: "What is the best teat dip?" In my opinion, the best teat dip is the one that is dripping from teats when the cow leaves the parlor. In the words, most of the products sold today effectively prevent IMI when used properly.
Animals↗
[Efficacy of various methods for preoperative vaginal antisepsis].
In a prospective clinical study we investigated 115 patients prior to vaginal surgical interventions to determine the antimicrobial efficacy of six different procedures for vaginal antisepsis. To sample the microorganisms we used a cotton swab moistened with a neutralising fluid. Immediately after the time of action of the antiseptic procedures (3 minutes), providone-iodine solution, applied undiluted or diluted 1:10, yielded the strongest median reduction of the vaginal flora (log RF 3.60 and 2.68, respectively). Of three detergents with antiseptic efficacy, octenidine 0.1% was the most efficient formula (log RF 2.32). After 30 minutes the log reduction factors (log RF) of almost all procedures (log RF 2.79-3.25) were in a fairly close range, excepting chlorohexidine 0.05% (log RF 2.07). Overall, the antiseptic detergents showed a marked residual effect, which was less pronounced, if at all, with providone-iodine solutions. A germ-reducing effect of povidone-iodine vaginal suppositories, applied 2 to 3 hrs prior to surgery, was not confirmed, while additional findings indicated that providone-iodine solution applied with the help of a vaginal douche yields a similarly strong germ reduction as the application by means of a ball swabs.
Adult↗
The role of iodine in antisepsis and wound management: a reappraisal.
For more than 150 years, iodine has been used for the prevention of infection and for the treatment of wounds. Nowadays a large amount of published evidence is available and, although it is generally in support of the use of iodine product, it is confused by being a mixture of laboratory, animals and human studies, often using different preparations. This makes interpretation and comparison difficult. After new developments and publications, the role of iodine in antisepsis and in wound management needs to be reevaluated. We mainly focused our review on the following problems: the role of the newly developed formulations of iodine preparations, its antimicrobial activity, the possibility of impairing the wound healing process, the role of iodine in the problem of growing resistance against antibiotics and antiseptics. New formulations seem to keep the same clinical efficacy, avoiding the problem of toxicity; it seems that the antibacterial activity of iodine is superior compared to other products and, in contrast with antibiotics and other antiseptics, it seems to have no resistance problem. It seems that povidone-iodine has all the characteristics to become the first choice antiseptic in wound treatment.
Anti-Infective Agents, Local↗
Skin antisepsis kits containing alcohol and chlorhexidine gluconate or tincture of iodine are associated with low rates of blood culture contamination.
OBJECTIVE: Skin preparation is an important factor in reducing the rate of blood culture contamination. We assessed blood culture contamination rates associated with the use of skin antisepsis kits containing either 2% alcoholic chlorhexidine gluconate or 2% alcoholic tincture of iodine. DESIGN: Prospective, blinded clinical trial. SETTING: Tertiary-care teaching hospital. PATIENTS: Adult patients in medical wards, the medical intensive care unit, and the cardiac intensive care unit who needed paired, percutaneous blood cultures. INTERVENTIONS: House officers, medical students, and healthcare technicians drew the blood for cultures. We prepared sacks containing all of the necessary supplies, including two different types of antiseptic kits. In each sack, one kit contained 2% chlorhexidine in 70% isopropyl alcohol and the other contained 2% tincture of iodine in ethyl alcohol and 70% isopropyl alcohol. Each patient received chlorhexidine at one site and tincture of iodine at the other. RESULTS: Four (0.9%) of 430 blood culture sets from 215 patients were contaminated. The contamination rate when using alcohol and chlorhexidine (1 of 215, 0.5%) did not differ significantly from the contamination rate when using tincture of iodine (3 of 215, 1.4%; P = .62, McNemar test). There was an 87% probability that the two interventions differed by less than 2% in their rate of contamination. CONCLUSIONS: Both of these antiseptic kits were highly effective for skin preparation prior to drawing blood for cultures. The use of these kits may have contributed to the low contamination rate observed in this study.
2-Propanol↗