Karin Falk-Brynhildsen

Bacterial recolonization of the skin and wound contamination during cardiac surgery: a randomized controlled trial of the use of plastic adhesive drape compared with bare skin

BACKGROUND Sternal wound infection after cardiac surgery is a serious complication. Various perioperative strategies, including plastic adhesive drapes, are used to reduce bacterial contamination of surgical wounds. AIM To compare plastic adhesive drape to bare skin regarding bacterial growth in wound and time to recolonization of the adjacent skin intraoperatively, in cardiac surgery patients. METHODS This single-blinded randomized controlled trial (May 2010 to May 2011) included 140 patients scheduled for cardiac surgery via median sternotomy. The patients were randomly allocated to the adhesive drape (chest covered with plastic adhesive drape) or bare skin group. Bacterial samples were taken preoperatively and intraoperatively every hour during surgery until skin closure. RESULTS Disinfection with 0.5% chlorhexidine solution in 70% alcohol decreased coagulase-negative staphylococci (CoNS), while the proportion colonized with Propionibacterium acnes was not significantly reduced and was still present in more than 50% of skin samples. P. acnes was significantly more common in men than in women. Progressive bacterial recolonization of the skin occurred within 2-3 h. At 120 min there were significantly more positive cultures in the adhesive drape group versus bare skin group for P. acnes (63% vs 44%; P = 0.034) and for CoNS (45% vs 24%; P = 0.013). The only statistically significant difference in bacterial growth in the surgical wound was higher proportion of CoNS at the end of surgery in the adhesive drape group (14.7% vs 4.4%; P = 0.044). CONCLUSION Plastic adhesive drape does not reduce bacterial recolonization. P. acnes colonized men more frequently, and was not decreased by disinfection with chlorhexidine solution in alcohol.

Decreased susceptibility to chlorhexidine and prevalence of disinfectant resistance genes among clinical isolates of Staphylococcus epidermidis

Staphylococcus epidermidis is a versatile agent, being both a commensal and a nosocomial pathogen usually with an opportunistic role in association with implanted foreign body materials. Pre‐operative antiseptic preparation is an important strategy for reducing the risk of complications such as surgical site infection (SSI). Currently, the most widely used antiseptics are alcohols, quaternary ammonium compounds (QACs), and the bisbiguanide chlorhexidine. Occurrence of resistance to the latter agent has drawn increasing attention. The aim of this study was to investigate if decreased susceptibility to chlorhexidine among S. epidermidis was present in our setting, a Swedish university hospital. Staphylococcus epidermidis (n = 143), retrospectively collected, were obtained from prosthetic joint infections (PJI) (n = 61), post‐operative infections after cardiac surgery (n = 31), and the skin of the chest after routine disinfection prior to cardiac surgery (n = 27). In addition, 24 commensal isolates were included. Minimum inhibitory concentration (MIC) of chlorhexidine was determined on Mueller Hinton agar plates supplemented with serial dilutions of chlorhexidine. Five QAC resistance genes, qacA/B, smr, qacH, qacJ, and qacG, were detected using PCR. Decreased susceptibility to chlorhexidine was found in 54% of PJI isolates, 68% of cardiac isolates, 21% of commensal isolates, and 7% of skin isolates from cardiac patients, respectively. The qacA/B gene was present in 62/143 isolates (43%), smr in 8/143 (6%), and qacH in one isolate (0.7%). The qacA/B gene was found in 52% of PJI isolates, 61% of cardiac isolates, 25% of commensal isolates, and 19% of the skin isolates. In conclusion, decreased susceptibility to chlorhexidine, as well as QAC resistance genes, were prevalent among S. epidermidis isolates associated with deep SSIs.

Bacterial colonization of the skin following aseptic preoperative preparation and impact of the use of plastic adhesive drapes.

Surgical site contamination, for example, with coagulase-negative staphylococci, probably derives from both the patient’s own skin flora and those of the surgical team. Despite preoperative antiseptic preparation with chlorhexidine solution, complete sterilization of the skin is not possible and gradual recolonization will occur. Plastic adhesive drape is an established method used to prevent direct wound contamination from adjacent skin. In this study, the time to skin recolonization after antiseptic preparation was measured and the impact of using plastic adhesive drape on this recolonization was evaluated. Repeated bacterial sampling using three different methods over 6 hr was conducted after antiseptic preparation in 10 volunteers. Recolonization of skin was observed after 30 min with plastic drape and after 60 min without plastic drape; there were significantly more positive cultures with the plastic drape than without (31% vs. 7.5%, respectively, p < .001). Sampling with a rayon swab was the most sensitive sampling method. In conclusion, covering the skin with a plastic adhesive drape seems to hasten recolonization of the skin after antiseptic preparation. However, clinical trials to confirm this finding are warranted.

Cardiac Surgery Patients’ Evaluation of the Quality of Theatre Nurse Postoperative Follow-Up Visit

Theatre nurses at the Department of Cardiothoracic Surgery in Örebro, Sweden, have since 2001 routinely conducted a follow-up visit to postoperative cardiac patients. A model with a standardized information part and an individual-caring conversation including both a retrospective and a prospective part designed the visit. The purpose of this study was to evaluate the quality of the postoperative follow-up visit conducted by the theatre nurses and find out if the quality was related to gender or type of admission. The method was prospective and explorative, including 74 cardiac surgery patients who had had a postoperative follow-up visit by a theatre nurse in Sweden. The instrument measuring quality, from the patients perspective, measured the quality of the visit, and consisted of 16 items modified to suit the study. The results showed an overall high quality rating, with statistically significant higher scores for six items between patients who had undergone emergency surgery, in comparison with elective patients. When comparing gender, women had statistically significant higher scores in two items. In conclusion, this postoperative follow-up visit by the theatre nurse was a valuable and useful tool especially for the patients who had undergone emergency surgery. In the follow-up visit the theatre nurse creates a caring relationship by meeting the patient as an individual with his/her own experience and needs for information about the surgery, intra and postoperative care, and recovery.

Psychometric Validation of the Perceived Perioperative Competence Scale-Revised in the Swedish Context

Purpose: To psychometrically test the Perceived Perioperative Competence Scale‐Revised (PPCS‐R) in the Swedish context. Design: Cross‐sectional survey. Methods: The 40‐item PPCS‐R was translated into Swedish using a forward‐translation approach. A census of 2,902 registered nurse anesthetists (RNAs) and operating room (OR) nurses was drawn from a database of a national association in Sweden. Finding: The response rate was 39% (n = 1,033; 528 RNAs and 505 OR nurses). Cronbach alpha for each factor was 0.78 to 0.89 among OR nurses and 0.79 to 0.88 among RNAs. Confirmatory factor analysis showed good model fit in the six‐factor model. Conclusions: Psychometric testing of the Swedish translation of the PPCS‐R suggests a good construct validity, and the construct and its six factors are conceptually relevant among the Swedish OR nurses and RNAs.

Exploring bacterial growth and recolonization after preoperative hand disinfection and surgery between operating room nurses and non-health care workers: a pilot study

BackgroundTo prevent cross infection the surgical team perform preoperative hand disinfection before dressed in surgical gowns and gloves. Preoperative hand disinfection does not make hands sterile and the surgical glove cuff end has been regarded as a weak link, since it is not a liquid-proof interface. The aims were to investigate if there were differences in bacterial growth and recolonization of hands between operating room nurses and non-health care workers as well as to investigate if bacterial growth existed at the surgical glove cuff end during surgery.MethodsThis pilot project was conducted as an exploratory comparative clinical trial. Bacterial cultures were taken from the glove and gown interface and at three sites of the hands of 12 operating room nurses and 13 non-health care workers controls directly after preoperative hand disinfection and again after wearing surgical gloves and gowns. Colony forming units were analysed with Mann-Whitney U test and Wilcoxon Sign Ranks test comparing repeated measurements. Categorical variables were evaluated with chi-square test or Fisher’s exact test.ResultsOperating room nurses compared to non-health care workers had significant higher bacterial growth at two of three culture sites after surgical hand disinfection. Both groups had higher recolonization at one of the three culture sites after wearing surgical gloves. There were no differences between the groups in total colony forming units, that is, all sampling sites. Five out of 12 of the operating room nurses had bacterial growth at the glove cuff end and of those, four had the same bacteria at the glove cuff end as found in the cultures from the hands. Bacteria isolated from the glove cuff were P. acnes, S. warneri, S. epidermidis and Micrococcus species, the CFU/mL ranged from 10 to 40.ConclusionsThere were differences in bacterial growth and re-colonization between the groups but this was inconclusive. However, bacterial growth exists at the glove cuff and gown interface, further investigation in larger study is needed, to build on these promising, but preliminary, findings.Trial registrationTrial registration was performed prospectively at Research web (FOU in Sweden, 117,971) 14/01/2013, and retrospectively at ClinicalTrials.gov (NCT02359708). 01/27/2015.

Response to M.H. Stevens and N.M. Klinger, re: Bacterial recolonization of the skin and wound contamination during cardiac surgery

Response to MH Stevens and NM Klinger, re : Bacterial recolonization of the skin and wound contamination during cardiac surgery