LAS VEGAS – Preoperative scrubs before nail avulsion fail to reduce postoperative infection, recent data suggest.
However, studies have identified best practices for reducing bacterial counts – such as irrigating after nail plate avulsion though there is no evidence that the measures reduce postoperative infection rates.
"Every study that has looked at rates of colonization or recolonization after your scrub showed significant bacterial presence. As good as our scrubs are, they're probably not good enough," Dr. Nathaniel J. Jellinek said at the annual meeting of the American College of Mohs Surgery.
A recent study measured bacterial counts after a 7-minute surgical scrub and again after avulsion of the nail plate. The bacterial counts were essentially the same. "It's as if the surgical scrub didn't do any good," said Dr. Jellinek, who was not involved in the study (Dermatol. Surg. 2010;36:1258-65).
The investigators then irrigated the nail bed with saline, which reduced bacterial counts by 95%. That's "an easy thing to do intraoperatively that you might consider for your practice," said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.
Studies published mainly in the podiatric and orthopedic literature show that postoperative infection rates are higher after nail surgery than after skin surgery. Rates of bacterial colonization before and after surgical preparation of nails make the term "sterile surgery" inaccurate for these procedures, which might better be considered clean-contaminated or even contaminated surgery, he said in an interview after his presentation.
Other studies have shown that applying alcohol and chlorhexidine may be superior to chloroxylenol and povidone-iodine to reduce bacterial counts before nail surgery. Bacterial persistence and recolonization also can be reduced by the use of bristled brushes, soaked gauze pads, scrubbing to the interdigital webs, and repeat scrubs.
"At this point, it's all hypothetical whether it decreases infection. But we know that infection rates are unacceptably high, so it can only help if you decrease the bacterial count," Dr. Jellinek said.
He has added multiple prophylactic measures to his practice, where he performs a lot of nail surgery.
First, Dr. Jellinek informs the patient that the nail is a dirty site, he reviews wound care, and educates the patient to pay attention to risk factors for infection and avoid putting fingers or toes in dirty places.
He recommends strict sterile preoperative and intraoperative techniques. A nurse or medical assistant should scrub the surgical area for several minutes. "We're talking not 10 or 30 seconds, but 2, 3, 5 minutes," he said.
The scrub should use multiple agents. He prefers using a bristle brush to scrub with chlorhexidine, gauze pads soaked in 70% isopropyl alcohol, and maybe even povidone-iodine paint. He lets all that sit, and applies a sterile glove over the digit, hand, or foot after the scrub.
During surgery, once the nail plate is avulsed, he recommends either performing a repeat scrub or at least irrigating the nail bed with sterile saline.
Dr. Jellinek said recent data have lowered his threshold for using prophylactic antibiotics. He has come to appreciate that nail infections may be caused by different organisms than those that cause most skin infections and require different antibiotics for treatment.
As a result, "I actually have very few nail infections, but I can't pinpoint which of those five or six things that I've done give me those results," he said.
Studies of prophylactic measures to avoid postoperative nail infections include:
- Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load (J. Am. Acad. Dermatol. 2009;61:986-92).
- Chlorhexidine Provides Superior Skin Decontamination in Foot and Ankle Surgery: A Prospective Randomized Study (Clin. Orthop. Relat. Res. 2005;438:204-8).
- Preoperative Skin Preparation of the Foot and Ankle: Bristles and Alcohol Are Better (J. Bone Joint Surg. 2005;87:986-92).
- Efficacy of Surgical Preparation in Solutions in Foot and Ankle Surgery (J. Bone Joint Surg. 2005;87:980-5).
Dr. Jellinek said he had no relevant financial disclosures.