THE EFFECT OF SKIN ANTISEPSIS AFTER PRIMARY SKIN CLOSURE ON THE INCIDENCE OF SURGICAL SITE INFECTION AFTER ABDOMINAL SURGERY FOR SEPSIS: A PRELIMINARY REPORT OF A RANDOMISED CONTROLLED TRIAL

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I.B Ulasi¹, E.O Aigbovo², A.I Michael3, O.O Ayandipo⁴, A. Fowotade², U.M Ishiyaka², C. Ezeme¹, N.A Olagunju¹, C.K Ikwu¹

1. Department of Surgery, University College Hospital, Ibadan.
2. Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan.
3. Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University College Hospital, Ibadan.
4. Division of Oncological Surgery, Department of Surgery, University College Hospital, Ibadan.

Abstract

Background: The role of skin antisepsis after skin closure in abdominal surgery for sepsis is not well reported. This study assessed the effect of skin antisepsis following primary skin closure on surgical site infection (SSI) after contaminated and dirty abdominal surgery.

Methods: This was a randomised controlled trial involving adult patient undergoing laparotomy for sepsis. Patients were randomised into a Control (C) group where the wound edge was cleaned once with 70% isopropyl alcohol before being covered with a dry sterile gauze dressing and a Povidone-iodine (PI) group in whom the wound edge was cleaned once with 70% isopropyl alcohol, then covered with a 10% povidone iodine-soaked gauze dressing. Both groups were compared for the presence of SSI. Statistical significance was set at a p value of <0.05.

Results: Thirty-seven patients (C group = 18; PI group = 19) were recruited. The median age was 36 years (Interquartile range, IQR = 72) with a male-to-female ratio of 2.7:1. The overall incidence of SSI was 48.6% (n = 18), comparable between the C group (n=10, 55.6%) and PI group (n = 8; 42.1%) (p = 0.413). In-hospital mortality rate was 10.8 % (n = 4), equally distributed between the groups (p = 1.000). The length of hospital stay was 8 days (IQR = 15) in the C group and 7 days in the PI group (IQR =9) (p = 0.169).

Conclusion: In laparotomy for sepsis, skin antisepsis after primary skin closure had no effect on the incidence of surgical site infection.

Keywords: Antisepsis, Skin closure, Abdominal Surgery, Sepsis

Introduction

The advances made in 21st century surgery were hinged mainly on a tripod of surgical technique with adequate haemostasis, anaesthesia and surgical antisepsis. Surgical practice in the prehistoric times was a fearful venture partly as a result of surgical site infection with attempts at its control foiled by failure to identify its aetiology.¹ Surgical site infection (SSI) was said to be so severe that surgeons rarely operated until the 1860’s.² The burden of surgical site infection has generally declined in recent decades with overall rates as low as 5% compared to 9.8% just three decades ago.^3,4

The microbial basis of infection was established by Louis Pasteur who discovered that tissue decay was caused by microbes.⁵ Based on this discovery, Joseph Lister propounded that the presence of microorganisms in surgical wounds was responsible for death in the post-operative period. He then started treating wounds with carbolic acid, hence the first use of antiseptic agent was credited to him.⁵

Over the years, greater attention to asepsis in surgery became the rule with agents and techniques used for this purpose undergoing modifications as more evidence became available. Current aseptic techniques involve a wide range of activities including instrument sterilization, use of sterile gloves and gowns, aseptic operating theatres suites, skin antisepsis and strict adherence to aseptic techniques during surgery.⁵ However, the effects of skin antisepsis – risks and benefits – need to be considered.

The human skin has a self-sterilizing activity which has been ascribed to various factors such as low pH and some antimicrobial agents, including small chain fatty acids.6 The resident bacteria are rarely pathogenic and may be a direct asset to their host.^6,7 For example, the human skin secrets sebum which is rich in triglycerides.⁸ The triglycerides are hydrolyzed by the resident bacteria to short chain fatty acids which provide an acidic medium that is in turn inhibitory to pathogenic microbes. It has, therefore, been noted that the continual reduction in the number of these resident flora by repeated application of an antiseptic agent may encourage not only cross infection with Gram negative bacteria but may become a source of tissue damage.⁹

Skin antisepsis refers to the use of chemical agents to destroy or inhibit the growth of micro-organisms in or on living tissue.¹⁰ It is traditionally carried out before surgical skin incision to reduce microbial load and ultimately the burden of SSI.^11-13 This is because the development of SSI depends on the virulence of the microbe, the host immune response and the dose of the inoculum.¹⁴ Various agents have been described to be effective in this regard, either singly or in combination. The commonly used antiseptics include alcohol-based (e.g., methylated spirit) iodophor-based (e.g., povidone-iodine) or chlorhexidine-based (e.g., savlon, hibitane) agents.¹⁵ These agents not only reduce the microbial load prior to skin incision but also exert varying degrees of antimicrobial activity (microbistatic or microbicidal). The beneficial role of this preoperative skin preparation has been fully established in several studies, persisting debate being essentially limited to which agent or combination of agents provides superior antiseptic benefit.^16-18

However, following skin closure after abdominal surgery, and cleaning the wound edges and surrounding skin of blood and other tissue fluid with a soapy antiseptic agent, some surgeons clean the apposed skin edge with an antiseptic solution, either isopropyl alcohol (more commonly) or povidone-iodine, before application of sterile dressings.¹⁹ The effects of this practice after skin closure in terms of post-operative wound outcome remains to be established. The aim of this study, therefore, was to examine whether skin antisepsis following skin closure in contaminated and dirty abdominal surgeries had an effect on surgical site infection in these patient.

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