PRE-INCISION SKIN ANTISEPSIS: PRACTICE PATTERNS AMONG SURGEONS IN NIGERIA

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I.B. Ulasi¹, A.I. Michael², O.O. Ayandipo³

1. Department of Surgery, University College Hospital, Ibadan, Nigeria
2. Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Nigeria
3. Division of Oncological Surgery, Department of Surgery, College of Medicine, University of Ibadan/ University College Hospital, Ibadan, Nigeria

Abstract

Background: Although studies are rife on preoperative skin antisepsis, little is known about what surgeons in Nigeria practice.

Objective: To describe the pattern of practice of skin antisepsis prior to skin incision among surgeons in select tertiary hospitals in Nigeria.

Method: This was a questionnaire-based descriptive cross-sectional survey involving surgeons and surgeons in training in the departments of surgery, obstetrics and gynaecology (O&G), otorhinolaryngology (ENT), and oral & maxillofacial surgery (OMS) of 26 select tertiary hospitals from all six geopolitical zones in Nigeria. Data was analysed using version 23 of the SPSS for Windows.

Results: A total of 200 surgeons participated in the study with a male-to-female ratio of 9:1. The mean age was 37.2 ± 5.2 years. Senior registrars constituted 60.5% (n=121), followed by registrars (24%; n= 48) and consultants (15.5%; n= 31). The respondents performed a mean volume of 4 surgeries per week. Their most common practice is to perform skin preparation with 3 antiseptic agents with skin scrubbing lasting for 3-4 minutes. Skin scrubbing was performed for longer duration amongst consultants compared with senior registrars and registrars. Of all the surgical wounds encountered in their practice, 57%were clean. The common complications associated with the use of these antiseptic agents include allergic dermatitis and blisters.

Conclusion: The practice of pre-incision skin antisepsis varies widely among Nigerian surgeons. The majority use 3 antiseptic agents for skin antisepsis although most of the procedures performed were clean surgeries. We recommend further studies to standardize our practice locally

Keywords: Skin antisepsis, Pre-incision, Pattern, Surgeons, Nigeria

Introduction

Before the mid-19th century, surgery was a dreaded venture due to the resultant complications like surgical site infection (SSI) at a time when little was known of the aetiological basis for these infections. ¹ Demystification of this puzzle of surgical infection, on account of which surgeons rarely operated till the 1860’s^,2 began when Louis Pasteur discovered the microbial basis for infection and tissue decay.³ Based on this discovery, Joseph Lister propounded that the presence of micro-organisms in surgical wounds was responsible for death in the post-operative period and then started treating wounds with carbolic acid, hence the first use of antiseptic agent was credited to him.³ Transient and resident microbes are ubiquitous on the human skin,⁴ These are commensals and opportunistic pathogens with no inherent ability to breach host barriers, unlike pathogenic microbes.⁵ Thus, a breach in skin integrity during surgical incision leads to contamination of deeper tissues and subsequent infection of the surgical wound.

Skin antisepsis, the process wherein chemical agents are used to destroy or inhibit the growth of microorganisms in or on living tissue⁶, is traditionally carried out before surgical skin incision to reduce microbial load and ultimately the burden of SSI.^7-9 This stems from the fact that microbial infection rests on a tripod of microbial virulence, the host immune response and the infective dose of the inoculum.¹⁰ The United States Centers for Disease Control and Prevention (CDC) classifies surgical wounds according to their degree of contamination into clean (class 1), clean contaminated (class II), contaminated (class III) and dirty (class IV) wounds. Clean wounds are uninfected operative wounds wherein no inflammation was encountered and a hollow viscus is not breached. They are usually closed primarily. In clean contaminated wounds, the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without spillage of contents to the operation site or wound. Included here are operations involving the biliary tract, appendix, vagina, and oropharynx. Contaminated wounds refer not only to operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered but also open, fresh, accidental wounds. Dirty wounds refer to traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. Here, the organisms causing postoperative infection were present in the operative field before the operation. Hence, pre-operative skin disinfection and cleaning is traditionally adopted as a key step in reducing surgical wound contamination and subsequent SSI based on a high level of evidence.^11-13 Commonly used antiseptics include alcohol-based (e.g. methylated spirit) iodophor-based (e.g. povidoneiodine) or chlorhexidine-based (e.g Savlon, Hibitane) agents¹⁴. These reduce the microbial load prior to skin incision and also exert varying degrees of antimicrobial activity (microbistatic or microbicidal).

While the beneficial role of this pre-operative skin preparation has therefore been fully established in several studies and persisting debate being essentially limited to which agent or combination of agents provides superior antiseptic benefit,¹⁵ there is little information on what surgeons practice with respect to pre-incision skin antisepsis in Nigeria. The aim of this survey therefore was to describe what surgeons in Nigeria practice with respect to skin antisepsis before
skin incision.

MATERIALS AND METHODS
This was a descriptive cross-sectional pilot survey carried out from May to July, 2019.

The study population were resident doctors (registrars & senior registrars) and consultants in the departments of surgery (including general surgery, urology, orthopaedics, neurosurgery, plastic surgery, cardiovascular and thoracic surgery and paediatric surgery), obstetrics & gynaecology, otorhinolaryngology, oral & maxillofacial surgery. Other surgeons with very little volume of skin surface surgeries like ophthalmologists were excluded from the surgery. Filling the questionnaire signified consent to participate in the study

Pre-tested questionnaires were distributed to respondents from select tertiary hospitals of the country using a convenience sampling method. Each respondent was provided with either a hard copy of the questionnaire or an online copy created using
Google forms. Three categories of data were sought: biodata, surgical experience, practice of pre-incision skin antisepsis and complications observed with the use of skin antiseptic agents.

Data was analyzed using mean and standard deviation for continuous variables while categorical variables were analyzed with proportions. Version 23 of the SPSS for Windows (SPSS Inc. Il, USA) was used to analyze all data obtained from the study.