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Infection Control Hotline

Products that help reduce HAIs

By Cindi Crosby

Source notes
Cindi Crosby is a clinical microbiologist for Cardinal Health, Dublin, Ohio, who works extensively with antimicrobial agents and their clinical applications. Crosby’s expertise includes laboratory and clinical settings as well as research and development within the industry. Crosby coordinates advocacy development and key opinion leader relationships for Skin Prep Solutions at Cardinal Health. She also researches medical practice and application of skin-disinfecting agents and provides clinical and technical information for education and in-service programs in infection prevention. She is a noted speaker nationally and internationally in the area of infection control.

Mature and intact epidermis is an effective barrier that prevents infection, but invasive and surgical procedures can break the barrier. Poor skin antisepsis is the primary source of health care-associated infections (HAIs). Staphylococcus aureus from a patient’s skin is the most common pathogen isolated from postoperative wound infections in clean surgical procedures. In clean-contaminated, contaminated and dirty-infected surgical procedures, different risks are present.

Q: What antimicrobial agents reduce microorganisms on patients’ skin?

Cutaneous or topical antiseptics must be active against resident and transient microorganisms on intact skin and reduce the number of microorganisms on the skin by mechanical removal, chemical action or both. Health care antiseptic formulations have a variety of modes and mechanisms—rapidity of antimicrobial activity, persistent or residual properties, demonstrating varying levels of toxicity. When selecting a product, consider safety and efficacy, quality of the evidence, ease of implementing, product availability, affordability and value. The ideal cutaneous antiseptic should have the following properties:

  • Broad spectrum of activity
  • Rapid bactericidal activity
  • Persistence or residual properties
  • Maintain its activity in the presence of organic matter
  • Be nonirritating or have low allergic and/or toxic responses
  • No or minimal systemic absorption.

Cutaneous antiseptics can be placed into seven specific categories: antimicrobial soap, skin wound cleanser, skin wound protectant, skin antiseptic, health care personnel hand wash, surgical hand scrub and patient pre-operative skin preparation (see Table 1). Predominate antiseptics include alcohol, iodine/iodophors and chlorhexidine gluconate (CHG).

Alcohols: Alcohols demonstrate excellent bactericidal effect on gram-positive and gram-negative bacteria. Alcohols are not effective against spores, but show acceptable activity against tubercle bacillus (tuberculosis). Alcohols have good fungicidal and virucidal activity and are very effective against human immunodeficiency virus. The mechanism of activity of alcohol is the property of denaturing proteins and quick evaporation. There are two common alcohols used in medical practice for skin antisepsis: isopropyl alcohol or ethanol (ethyl alcohol).

There are minimal differences in the antimicrobial effects of these two alcohols. Concentration of the alcohols is the most important asset when evaluating the antimicrobial effect of the two alcohols. Alcohols between 70 percent and 90 percent (volume per volume) are the most effective. The major disadvantages are that no residual property is left on the skin. Isopropyl alcohol is drying to skin, is less efficacious than CHG, and povidone-iodine (PI) and has been associated with chemical burns in premature infants. Topical alcohols have been shown to facilitate percutaneous absorption and are associated with newborn hypoglycemia and central nervous system depression.

Iodine/iodophors: Iodophors are solutions of iodine-containing anionic and nonionic complexes that contain a low amount of free iodine, usually ranging from 0.8 percent to 1.2 percent. PI (i.e., Betadine–10 percent PVP-I) is an iodophor of iodine, polyvinylyrrolidine (PVP) and detergent. The range of PVP-I solutions is between 7.5 percent and 10 percent, which has 0.75 percent to 1 percent titratable iodine for skin antisepsis. These solutions are less irritating to skin because of low amounts of free available iodine. The iodophors must have a 2-minute or more contact time with skin to allow for the release of free iodine. Iodophors have approximately a two-hour residual property. Once iodine is combined with organic matter such as blood, bacteria, etc., it is neutralized and is not effective. Iodophor solutions have been associated with microbial contamination. Multiuse iodophor bulk bottles have become contaminated with normal use in the hospital setting.

Tinctures of iodine and iodophors are known for skin irritation and have been known to have allergic or toxic effects on sensitive individuals. Percutaneous absorption can occur, altering thyroid function in premature and full-term newborns.

Chlorhexidine: CHG is a cationic bi-guanide. Its antimicrobial action is the disruption of the cell membrane and the precipitation of cell contents. It is a broad spectrum antiseptic against gram-positive and gram-negative bacteria. It is a fair fungicidal and is effective against most viruses. It has a superior residual property compared with available skin antiseptics in the United States. CHG has a strong binding property to skin and has a residual property that has been documented at 48 hours. CHG is not neutralized in the presence of organic matter. It is a superior skin antisepsis in preventing local or cutaneous infections prior to insertion of an intravascular device. CHG is a large chemical compound with little systemic absorption and low toxic effects. Several studies with CHG indicate this compound is absorbed minimally through intact human skin. 

Other antimicrobial agents include para-chloro-meta-xylenol (PCMX) and triclosan, which have appeared in the antiseptic market over the past 10 years. The modes and mechanisms of PCMX and triclosan are still being studied. Comparative, prospective and random studies are few for these two compounds.

PCMX is a broad-spectrum antimicrobial agent with good activity against gram-positive organisms, but demonstrates a lesser antimicrobial activity against gram-negative bacteria, especially the Psuedomonas species. It has a fair antimicrobial activity against fungi and viruses.

In several studies, PCMX is less effective than PVP-I or CHG in reducing skin flora. The antimicrobial activity of PCMX is minimally affected by the presence of organic matter, but is neutralized by nonionic surfactants. Absorbed through the skin, PCMX is usually well tolerated and allergic reactions are uncommon. In-use contamination of a PCMX-containing preparation has been reported.

Triclosan is a diphenyl ether. Its antimicrobial activity is reported to be from the disruption of the microbial cell wall. Triclosan is a broad-spectrum antimicrobial agent that works well for gram-positive and gram-negative bacteria.

It is a poor fungicidal and its antimicrobial activity is unknown for viruses. It has an excellent residual property on the skin and is not affected by organic matter. It can be absorbed through intact skin but has shown little toxic effect.

In the neonatal intensive care setting, a 0.3 percent triclosan hand-washing agent and infant bathing ended a seven-month methicillin-resistant Staphylococcus aureus nosocomial outbreak.

A 1 percent triclosan formulation for handwashing halted an MRSA outbreak in a neonatal facility. Additional safety and efficacy data are needed for topical cutaneous and/or preoperative skin preparation applications before a final assessment can be made.

Q: Does it make a difference what type of drapes are used?

Yes. The main purpose of a surgical drape is to create a barrier between nonsterile areas and sterile areas within the operating room to create a sterile field.

To create such a barrier, various types of materials are used on the surgical drape. In addition, the Association of the Advancement of Medical Instrumentation (AAMI) has created an industry-recognized guideline for all manufacturers to follow that highlights the levels of barrier protection that a surgical drape can provide. Four tests related to barrier are conducted around the “critical zone” or the area surrounding the fenestration.

There are four levels of barrier protection as outlined in the AAMI PB70:2003 standard, 1-4. Level 1 provides the lowest level of protection and Level 4 provides the highest. Although most surgical drapes include an impervious reinforced area around the fenestration (Level 4), there are certain fabrics used to make up the base portion of the drape.

Reusable linens: These linens create a soft and drapeable product for use in the operating room. However, they have significantly lower levels of barrier protection than many disposable fabrics, have very high lint properties and create a significant risk for fires within the OR if in contact with a heat source for a prolonged period.

Spunlace fabrics: This material feels very clothlike; however it does not provide the highest level of barrier protection. It is made from short wood pulp fibers, which can easily catch fire and have the ability to generate higher levels of lint.

Spunbond meltblown spunbond (SMS): This material is self-extinguishing when in contact with a heat source and has lower levels of lint properties because it is made from polypropylene resins and longer fibers. This material provides a significantly higher level of barrier protection than Spunlace or reusable products.

Spunbond film spunbond: This is the only fully impervious surgical drape material that performs similarly to SMS materials. However, with the hidden film middle layer, it does not allow for any blood or bacteria/viruses to pass through. It also self-extinguishes and has the lowest level of lint properties possible.

Q: What are care bundles and how can they improve patient outcomes?

The Institute for Healthcare Improvement’s (IHI) 100,000 Lives and 5 Million Lives campaigns, Surgical Care Improvement Project and the Association for Professionals in Infection Control and Epidemiology’s Zero Tolerance Campaign have outlined evidence-based practices and/or procedures known as bundles, aimed specifically at reducing HAIs and other unnecessary hospital events. These are defined as groups of scientifically validated processes for patients at risk. Bundles vary depending on the condition being addressed. For example, the appropriate bundle for ventilator-associated pneumonia calls for the head of a patient to be elevated, waking a patient daily for assessment and taking preventive steps to prevent blood clots and ulcers.

There are bundles for prevention of surgical-site, central-line catheter infections and sepsis. According to IHI, bundling the steps makes patient care a collaborative effort. Rather than acting independently, doctors, nurses, therapists and pharmacists should work together.  

About this column

This column presents answers and practical guidance to some of the most commonly asked questions of suppliers and educators in the infection control and sterile processing communities. To submit a question to the column, e-mail Bob Kehoe, executive editor, at rkehoe@healthforum.com.

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  • OSTRANDER…
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Table 1. Categories of cutaneous antiseptic solutions

Category Definition
Antimicrobial soap Soap containing an active ingredient with in vitro and in vivo activity against skin microorganisms.
Skin wound cleanser Safe, nonirritating liquid preparation that assists in removing foreign material from small superficial wounds and does not delay healing.
Skin wound protectant Safe, nonirritating preparation applied to small, cleansed wounds that provides a protective barrier and does not delay healing nor aids in the growth of microorganisms.
Skin antiseptic Safe, nonirritating antimicrobial-containing preparation that prevents skin infection.
Health care personnel hand wash Safe, nonirritating antimicrobial preparation designed for frequent use. It should be broad spectrum, fast-acting and persistent.
Surgical hand scrub Safe, fast-acting, broad-spectrum, persistent, non-irritating antimicrobial-containing preparation that significantly reduces the number of microorganisms on intact skin.
Patient pre-operative skin preparation Safe, fast-acting, broad-spectrum, antimicrobial-containing preparation with minimal irritation that significantly reduces the number of microorganisms on intact skin.

This article first appeared in the September 2008 issue of Materials Management in Health Care.

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