Preoperative Bathing

A measure with different recommendation fields

Why is preoperative bathing a measure worth mentioning

The WHO states:1

“Preoperative whole-body bathing or showering is considered good clinical
practice to make the skin as clean as possible prior to surgery in order to
reduce the bacterial load, especially at the site of incision.”

In literature you can also find the following:2
• “microorganisms isolated in SSI in clean surgery are mainly
those of the skin flora”
• “skin preparation reduces the skin flora and hence the risk of SSI”

Guidelines

Guidelines

Guideline

Recommendation

Category (if mentioned)

CDC3

“Advise patients to shower or bath (full body) with soap (antimicrobial or non antimicrobial) or an antiseptic agent on at least the night before the operative day.”

Category IB,
strong recommendation; accepted practice

“Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths for the prevention of SSI.”No recommendation,
unresolved issue

WHO1

“It is good clinical practice for patients to bathe or shower prior to surgery.”

Conditional recommendation, moderate quality of evidence

“The panel suggests that either a plain or antimicrobial soap may be used for this purpose.”
“The panel decided not to formulate a recommendation on the use of chlorhexidine gluconate (CHG)-impregnated cloths for the purpose of reducing SSI due to the limited and verylow qualityevidence.”

NICE4

“Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap, either the day before, or on the day of, surgery.”

-

KRINKO5

The commission recommends, in cardiac and orthopedic surgery, patients with nasal colonization with S. aureus should undergo preoperative decolonization of the nose with mupirocin nasal ointment 2% alone or in combination with body washing with chlorhexidine gluconate.

Category IB

The Commission recommends that the skin of the patient's surgical area be thoroughly cleaned outside the surgical department.Category II

HARTMANN:

Denise Leistenschneider, Senior Clinical Consultant
"The human skin plays a decisive role in the development of SSI and should therefore be given special attention in prevention."

Clear recommendations

  • Shower/bathing/skin cleaning by the patient (or with help) prior to surgery1,3–5

  • Bathing with plain or antimicrobial soap1,3,4

No clear recommendations regarding

Icon of a dialogue
  • Time of bathing1

  • Total amount of soap or antiseptic agent1

  • Use of chlorhexidine gluconate washcloth1,3

Resident flora vs. transient flora 6

  • Resident flora: bacteria living permanently on human skin contributing to health by inhibiting establishment of harmful yeast and fungal infections.

  • Transient flora: number of bacteria transferred from other people or from the environment that are only present on the skin for a short period of time.

Uncertainties formulated by the WHO 7

“The lack of new evidence suggests that practices are already established and accepted in the medical community. In the light of emerging patterns of resistance developing with antiseptic use and the potential for adverse events, it may be important for future research to investigate whether the use of antiseptics is pertinent and to re-evaluate the efficacy of non-medicated soap or no bathing vs. preoperative bathing with antiseptics in a variety of settings, particularly in low- and middle-income countries. Safety associated with the use of a non-rinse application of CHG should be evaluated also.”

Click to see full list References
  1. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018.
  2. Jolivet S, Lucet JC (2019) Surgical field and skin preparation. Orthopaedics & Traumatology: Surgery & Research 105: S1–S6.
  3. Berrios-Torres SI, et al. (2017) Centers of Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg
    152(8): 784–791.
  4. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020.
    www.nice.org.uk/guidance/ng125.
  5. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention
    (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
  6. Webster J, Osborne S (2015) Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev Feb 20; 2015(2): CD004985.
  7. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018. Web Appendix 2: Summary of a systematic review on preoperative bathing.

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