Becker's Clinical Quality & Infection Control

12 Executive Briefing 2 EXECUTIVE BRIEFING SPONSORED BY Choosing the Right Skin Antiseptic Preoperative skin antisepsis is a critical part of reducing the bacteria on the skin that may cause infection prior to surgery. The most common products used in the United States include alcohols, chlorhexidine, iodine, and iodophors as either single-agent preps or in combination. There are important aspects to the safe and effective use of these products and challenges to the variability in applying these antiseptics correctly. There are many factors to consider in the determination of which antiseptic to use for a particular patient. Becker's interviewed Lena Pearson RN, BSN, MS, CNOR BD Associate Director for Medical Affairs, to provide some insights on this topic. Question: What are some important considerations when choosing the right skin antiseptic for surgery? Lena Pearson (LP): When selecting a skin antiseptic, the active ingredient should not be the only consideration. Several other factors need to be considered: • Evidence – Published peer-reviewed randomized controlled trials are important to weigh the efficacy of an antiseptic in clinical practice. • Safety – Review whether there is a history of safety with the use of the antiseptic, especially with more compromised patient populations. • Supply – In a complex post COVID global economy, ensuring adequate supply capabilities is important. • IFUs – It is important to note that different manufacturers may have different instructions for use. Antiseptic manufacturers' IFUs convey important safety and efficacy instructions to the user. Failure to adhere to the manufacturer's IFU may result in patient harm or ineffectiveness of the preoperative patient skin antiseptic. • Cost – When reviewing the cost of antiseptics, it is important to review contracts, the cost to add the prep to surgical packs, and the additional value offered by the manufacturer or supplier. Q: Who should be involved in the selection? LP: AORN recommends that you first convene an interdisciplinary team that includes one or more perioperative RNs, physicians, and infection preventionists to evaluate and select antiseptic products for surgical site preparation. ¹ This group can also include Infectious Disease, Patient Safety and Quality, Surgeons, Value Analysis Managers, Procurement, and Supply Chain. Decisions about which preoperative skin antiseptic to use in the practice setting are complex. A variety of products may be necessary to meet the needs of various patient populations. Input from an interdisciplinary team with diverse experience and knowledge of skin antiseptics is helpful during the review of the current research, clinical guidelines, and information provided by the manufacturers of surgical antiseptic agents. Lastly, the involvement of an interdisciplinary team also facilitates input from all departments in which the product will be used and from personnel with clinical expertise.¹ Q: Who should be involved in the selection? LP: Skin antiseptics should be supported by clinical evidence. Meta-analysis and systematic reviews of randomized controlled trials are considered the highest levels of clinical evidence. The more rigorous the standards, the less potential for bias and the better the quality of evidence. It is important to note that the efficacy of any formulation is significantly affected by the excipients present. Therefore, trials demonstrating the activity of one formulation cannot be used as evidence for the efficacy of another. 2 Study methodology and results need to first be vetted to identify potential bias. Some of these considerations include appropriate sample size (Ns), use of comparators that represent standard of care, meeting of primary and/or secondary endpoints, relevant metrics being used, and the statistical significance of data presented. 3,4 Q: What factors should be determined when selecting a skin antiseptic with a tint? LP: The tint of a skin antiseptic is important to delineate the area that has been prepped. Selecting the right tint is important so that it is visible on a variety of skin tones.¹ Selection of tint color is also important to reduce clinical misdiagnoses from skin coloring during post-op care. Q: What factors should be determined when selecting a skin antiseptic with a tint? LP: Persistence is defined as the suppression of bacteria growth less than or equal to pre-treatment counts. 5 Maintaining low levels of bacteria on the skin while healing is important to minimize bacteria entering the puncture or incision site. While a mature, intact epidermis is an effective barrier to infection, surgery and other invasive procedures break the skin's barrier, allowing the migration of skin-dwelling and environmental microorganisms into the wound, and increasing the risk of local or systemic infection. 6 Once the skin barrier is broken, the inflammatory phase of wound healing (when microorganisms are killed in the wound by immune cells) peaks at 24-48 hours and lasts for several days. Persistence can help minimize the number of microbes that enter the wound during this time period. Re-epithelization

• Cover