Dear Readers:

   What have we learned about preventing surgical site infection since 1867 when Lister first prevented surgical site suppuration and septicemia by using carbolic acid to wash wounds, soak dressings, and spray operating room air? In an experiment that laid the foundation for modern surgery,¹ 9 of Lister’s 11 compound fracture patients healed without amputation or mortality typical of that era. Do we know today which of Lister’s precautions was effective? Carbolic acid was soon replaced with less irritating aseptic technique. More recently, gentler topical antimicrobials with sustained delivery like mupirocin, cadexomer iodine, or ionic silver have been added to the antimicrobial armamentarium. Today, it is surprising how little we know regarding effective usage parameters of antimicrobial agents in preventing surgical site infections (SSI) or their benefits and drawbacks. A Cochrane review,² discussed in the April 2008 Evidence Corner, found some evidence that cadexomer iodine improved venous ulcer healing, but concluded that further research would be needed to make a definitive conclusion. Antimicrobial agents still require more evidence for optimally safe, effective usage in surgical wound care. The two recent articles featured in this Evidence Corner give us a surprising view of surgical drape safety and efficacy and offer tentative hypotheses regarding steps to prevent SSI with methicillin-resistant Staphylococcus aureus (MRSA).

Laura Bolton, PhD, FAPWCA
Adjunct Associate Professor
Department of Surgery, UMDNJ
WOUNDS Editorial Advisory Board Member and Department Editor

Do Antimicrobial Surgical Drapes Prevent Infection?

   Reference: Webster J, Alghamdi AA. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev. 2007;(4):CD006353.

   Rationale: Surgical site infection (SSI) occurs in an estimated 15% of clean surgeries and 30% of contaminated surgeries. Plastic adhesive drapes with and without antimicrobial agents is a popular method of protecting the wound from SSI, but conflicting results place their efficacy in question.

   Objective: Conduct a Cochrane review of evidence supporting efficacy and cost effectiveness of surgical drapes in preventing SSI, mortality, and morbidity.

   Methods: MEDLINE, Ovid, and Cochrane databases were searched through April 2007 for randomized controlled trials (RCTs) comparing a plastic adhesive drape with no adhesive drape, used alone, or with woven or paper materials on patients undergoing any type of surgery. Two authors independently reviewed each publication and abstracted method and results sections. Outcome measures included SSI incidence, cost, mortality, morbidity, and length of hospital stay (LOS).

   Results: In 5 studies involving 3082 participants comparing adhesive drape use with no drape, more patients who were managed with the adhesive drape developed a SSI (P = 0.03). Combined analysis of two studies with 1113 participants found no difference in SSI between groups (P = 0.89) managed with an iodine-impregnated adhesive drape compared to no drape. Adhesive drape use did not affect LOS.

   Authors’ Conclusions: Based on the 7 RCTs qualifying for analysis, there is no evidence that plastic adhesive surgical drapes reduce SSI, and some evidence that these drapes increase SSI rates unless impregnated with iodine. Further RCTs are needed using blinded outcome assessment of SSI on wounds with different SSI risk classifications, such as depth and level of contamination.

Preventing MRSA-derived Surgical Site Infection

   Reference: van Rijen MM, Kluytmans JA. New approaches to prevention of staphylococcal infection in surgery. Curr Opin Infect Dis.