Two Treatments Curbed Surgical Site Infections

Disclosures: Dr. Darouiche reported receiving research and educational grants from Cardinal Health. Dr. Bode's study was supported by grants from ZonMw, Mölnlycke Health Care, GlaxoSmithKline, Roche, bioMérieux, and 3M.

My Take

Chlorhexidine Prep Clearly Superior

These are both high-quality studies, but I believe that the findings reported by Dr. Darouiche and colleagues will have more immediate impact. They convincingly demonstrate that a chlorhexidine-alcohol prep is superior to the traditional povidone-iodine solution. Chlorhexidine previously has been shown to be clearly superior to povidone-iodine when used as a skin prep for central venous catheter insertion.

The authors found that the chlorhexidine-alcohol product showed relatively greater superiority in the prevention of superficial incisional surgical site infections and relatively less in preventing more serious infections. Still, the overall benefit associated with the chlorhexidine solution suggests that hospitals not already using it as a surgical prep should begin doing so.

The study by Dr. Bode and colleagues is intriguing, showing that real-time PCR screening of primarily surgical patients on or before admission, coupled with a 5-day course of intranasal mupirocin and chlorhexidine baths, significantly decreased the incidence of nosocomial Staphylococcus aureus infections. This was particularly true of deep surgical site infections, a sometimes devastating complication.

However, the study has limitations that I believe will prevent the results from being immediately embraced in this country. None of the S. aureus isolates in the study were methicillin resistant, yet in the United States, a high percentage of colonizing isolates are community-associated MRSA, and an increasing percentage of those are mupirocin resistant. Also, a recent large Swiss study employing a similar “search and destroy” strategy for MRSA colonization before surgery failed to show benefit (JAMA 2008;299:1149–57).

But I agree with Dr. Wenzel's suggestion in the editorial (N. Engl. J. Med. 2010;362:75–7) that real-time PCR screening and decolonization is probably appropriate for surgical patients where the stakes are especially high (e.g., cardiothoracic procedures and total joint replacements).

JAMES PILE, M.D., a hospitalist and infectious diseases specialist, is the acting director of the Division of Hospital Medicine for the MetroHealth campus of Case Western Reserve University, Cleveland, Ohio. He reported no conflicts of interest.