CORR Insights^®: Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?

Where Are We Now?

Periprosthetic infection remains one of the most severe and costly complications after total joint arthroplasty, and both the incidence and total number of patients with this problem are increasing [3]. By 2020, there will be an estimated 65,000 prosthetic joint infections annually, with an estimated hospital cost of USD 1.6 billion [3].

Most treatment options are costly, may require additional surgical procedures with prolonged disability, and are moderately successful at clearing the infection [4]. Prevention is the ideal approach to reduce the burden of surgical site infection (SSI), and the study by Kapadia and colleagues provides evidence for an additional preventative measure to decrease periprosthetic infection rates using cloth-based chlorhexidine application prior to surgery. Although the efficacy of chlorhexidine application for preventing central catheter-based infections, methicillin-resistant Staphylococcus aureus infections in ICU patients, and skin colonization in surgical patients has been well established, the effectiveness of presurgical chlorhexidine skin application for preventing SSI remains unproven [5]. Indeed, a recent Cochrane Review [6], as well as a recent meta-analysis [1], both found no evidence that presurgical washing or bathing with chlorhexidine reduces SSI. Some of the studies used chlorhexidine showers with a limited duration of application, which may have decreased their efficacy. Farber and colleagues [2] also found that a single application of 2% chlorhexidine wipes 1 hour before surgery did not decrease SSI in total joint arthroplasty patients [2].

The authors of the current study suggest using 2% chlorhexidine wipes the night before surgery and the morning of surgery, as this approach resulted in a considerably reduced SSI rate (> 75% reduction) in patients undergoing TKA. Kapadia and colleagues used multiple applications of chlorhexidine, which remained on the skin for an extended duration (as opposed to washing it off right away). By doing so, the authors may have achieved better results compared to previously published studies [1, 6].

Where Do We Need To Go?

A large randomized controlled trial with better compliance is necessary to confirm the efficacy of pre-surgical chlorhexidine wipes for reducing surgical site infection. The correct frequency, timing, and technique of chlorhexidine wipe application also has yet to be determined. Chlorhexidine skin application appears to be safe, with adverse reactions primarily limited to dermatitis and rashes [5]. Chlorhexidine wipes are associated with poor patient compliance, and these adverse reactions could be the culprit. More information is needed regarding the incidence of skin reaction and the reasons for noncompliance in joint replacement patients. The cost of a single application is approximately USD 5, which is certainly cost-effective if the SSI rate is decreased by any meaningful amount. The development of resistance with widespread use remains a concern, although the evidence for that is limited thus far [4].

How Do We Get There?

A definitive demonstration of the value of presurgical chlorhexidine wipes for decreasing SSI in patients with total joint arthroplasty will require a large, randomized, controlled study that is sufficiently powered to measure a difference in SSI rates not simply skin colonization. A multicenter trial is likely needed given the sample size required to determine a substantial difference in SSI rates. Ideally, the study should be powered to compare low-risk patients versus high-risk patients who used wipes. Perhaps presurgical chlorhexidine wipes should be reserved for medium- and high-risk patients. Efforts to improve compliance, as well as monitoring adverse reactions, would also be an important part of further studies. The large number of available arthroplasty patients, the low cost of the wipes, an easily measured end-point of infection, and the relatively short duration of followup required (3 months to 12 months) should make this a manageable study, even with the large number of patients required. The large national arthroplasty organizations (American Association of Hip and Knee Surgeons, The Hip Society, The Knee Society, Musculoskeletal Infection Society) would have access to surgeons who care for many arthroplasty patients, and may be in a position to facilitate this kind of study.

Kapadia and colleagues have provided the orthopaedic community with evidence for an important initial step toward further reducing periprosthetic infection rates with a low-risk and low-cost treatment. This work creates a strong rationale for additional studies to answer the question more definitively.