From Phisohex to Hibiscrub

In a field trial of three disinfectant-detergent preparations for the surgical scrub Hibiscrub (a 4% chlorhexidine detergent solution) maintained a significantly greater residual antibacterial action on the skin of the gloved hands of an operating team than was obtained with Disadine (povidone-iodine detergent preparation) (P<0·001). In comparison with Phisohex (3% hexachlorophane in detergent cream), the established surgical scrub of the operating team for many years, Hibiscrub maintained marginally more significant residual disinfection (P 0·05). Of the three preparations the members of the team found Hibiscrub to be more acceptable for use than either Disadine or Phisohex.     

Use of 4% Chlorhexidine Detergent Solution (Hibiscrub) and Other Methods of Skin Disinfection

In a comparison of three antiseptic detergent preparations for hand washing, Hibiscrub, a 4% chlorhexidine detergent solution, caused a significantly greater estimated immediate reduction of skin flora (86·7% ± 3·0) than was obtained with Dermofax, a 0·75% chlorhexidine detergent solution (55·5% ± 5·1), or with Disadine scrub, a povidone iodine detergent preparation (68% ± 6·8). After six applications the mean estimated reductions of skin flora were 99·2% ± 0·2 for Hibiscrub, 97·7% ± 0·7 for povidone iodine, and 91·8% ± 1·6 for Dermofax.After a series of hand washings with Hibiscrub, as with a hexachlorophane detergent preparation, a further large reduction of skin flora, shown by bacterial counts of hand sampling, was obtained by a second phase of disinfection consisting of two minutes'' application on gauze swabs of 0·5% chlorhexidine digluconate in 70% ethanol; a further wash with Hibiscrub, in place of alcoholic chlorhexidine, for the second phase of disinfection caused an increase rather than a reduction in the yield of bacteria on skin sampling. Unlike this “two-phase” disinfection, the application for 30 minutes of compresses soaked in 10% aqueous povidone iodine or in 0·5% aqueous chlorhexidine digluconate did not cause a greater reduction in skin flora than that obtained by the conventional two minutes'' application on gauze of 0·5% chlorhexidine in 70% ethanol.Chlorocresol (0·3%) liquid soap (the base used for Ster-Zac liquid hexachlorophane soap) caused a mean reduction of skin flora when used for hand washing of 29% after one application and 72% after six applications spread over two days. This formulation, though less active and more variable as a detergent skin antiseptic than chlorhexidine, hexachlorophane, or povidone iodine detergent preparations, is an inexpensive disinfectant soap which could be useful in catering establishments. Alcoholic cetrimide applied as for disinfection of an operation site caused a reduction of skin flora greater than that shown by aqueous cetrimide but comparable to that shown by 70% ethyl alcohol in previous experiments.     

No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study

The development of antisepsis in the late nineteenth and early twentieth centuries revolutionized health care. The time-honored technique of skin preparation is to scrub the entire operative area of the patient for 5 to 7 minutes with a germicidal detergent solution and then paint the region with an antimicrobial solution of either tincture of povidone-iodine (Betadine) or chlorhexidine. Although antiseptics result in lower colony counts on the skin, they have side effects and higher cost in relation to normal saline. The authors have prepared patients by showering the surgical site with soap and water and rinsing it with normal saline, in 905 cases of outpatient, clean-wound plastic surgery. In another 905 cases that served as the control group, the traditional method of preoperative shower and scrub with chlorhexidine or Betadine was used. In both groups, there was no incidence of wound infection.     

Disinfection of the Skin: An Assessment of Some New Preparations

Repeated hand washing with a detergent solution containing 0·75% chlorhexidine digluconate was found to cause a large reduction in the resident skin flora which was slightly though significantly smaller than that caused by the use of 3% hexachlorophane liquid soap containing a phenolic preservative, chlorocresol 0·3%. Both agents caused a greater immediate reduction of bacteria after a single hand washing than the hexachlorophane liquid soap without a phenolic additive had shown in earlier experiments; the soap base containing chlorocresol 0·3% but no hexachlorophane was also found to cause a large reduction in skin flora. The chlorhexidine detergent solution had no residual disinfectant action on the skin after rinsing and drying the hands.Disinfection of an operation site for two minutes with povidone-iodine containing 1% available iodine in 70% ethyl alcohol caused about as great a reduction in resident flora as a similar treatment with alcoholic 0·5% chlorhexidine. Both treatments were more effective than disinfection with aqueous 1% cetrimide or 0·1% benzalkonium chloride solutions.     

Rotavirus inactivation by chemical disinfectants and antiseptics used in hospitals

Nosocomial outbreaks of rotaviral gastroenteritis are a common occurrence. Although proper disinfection practices in the hospital environment are considered to be important in the prevention and control of such outbreaks, very little information has been available on the rotavirus-inactivating capacity of chemical disinfectants and antiseptics commonly used in hospitals. In view of this, 11 such products were selected and screened for their capacity to bring about at least a 3 log10 reduction in the plaque titre of rotavirus SA-11 after a contact time of 1-30 min. Consept "D" (1:100), D.R.X. (1:80), Dustbane Germicidal (1:80), Hibitane, and Wescodyne (1:200) were found to be ineffective under these test conditions even in the absence of an added organic load. The virucidal capacity of Savlon (1:200) and Zephiran was completely neutralized when single-strength tryptose phosphate broth was added to the virus-disinfectant mixture to simulate an organic load. Cidex (2% acid glutaraldehyde), Proviodine (10% solution of povidone-iodine), Septisol (0.75% hexachlorophene), and Sana Rinse (70% isopropylalcohol, 0.1% hexachlorophene) were able to produce at least a 3 log10 (99.9%) reduction in the virus plaque titre even in the presence of added organic matter. These findings should be of help in the prevention and control of outbreaks of rotaviral diarrhea in the hospital environment.     

Physical, biomechanical, histologic, and biochemical effects of rapid versus conventional tissue expansion

Clinical tissue expansion has been quite successful but takes 2 to 3 months. This study compares the effects of a conventional tissue expansion regimen of 6 weeks with an accelerated regimen of 2 weeks in the dog model, which is biomechanically similar to the human. In 22 dogs, the skin expanded 34.4 percent in the 2-week and 35.8 percent in the 6-week protocol, excluding stretch and recruitment. There was thinning of the panniculus carnosus in the 6-week group and otherwise no significant decrease in dermal thickness in either group. The biomechanical properties of elasticity and creep did not differ in expanded skin from both groups, while stress/relaxation mildly decreased from a control value of 53.5 percent to 48.8 percent in the 6-week group (p less than 0.05). Collagen activity was increased in both the 6-week and the 2-week groups (p less than 0.001) over nonexpanded skin, and immunohistochemical staining with a monoclonal procollagen antibody demonstrated collagen synthesis by dermal fibroblasts in both groups. We conclude that rapid tissue expansion did not demonstrate any deleterious effects when compared with a conventional regimen.     

Evaluation of a cup scrub technique for quantification of the microbial flora on bovine skin

L loyd , D.H. 1984. Evaluation of a cup scrub technique for quantification of the microbial flora on bovine skin. Journal of Applied Bacteriology 56 , 103–107.
A cup-scrub technique devised for sampling the human skin surface microfiora was evaluated in cattle. Scrub samples from bovine skin contained clumps of squames and bacterial microcolonies which were progressively broken down by shaking. This was accelerated in the presence of ballotini beads but aggregations of bacteria were still present after prolonged agitation. Vigorous shaking, particularly with beads, decreased the viability of the bacteria and optimum viable counts were obtained after manual shaking for half a minute. Immersion in buffered detergent, wash and diluting fluids for up to 2 h promoted release of bacteria from micro-colonies but decreased the viability of aerobic and anaerobic pleomorphic rods and a Bacillus strain. There was no significant effect on strains of Micrococcaceae. Prolonged exposure of bacteria from scrub samples to these fluids can thus lead to both quantitative and qualitative alterations in the counts: obtained, although these effects may be masked by the continuing release of bacteria from microcolonies. The cup-scrub technique provides a convenient means of quantifying changes in the bovine skin microfiora but results obtained from different studies should only be compared if closely similar techniques are used.     

Increased permeability-oedema and atelectasis in pulmonary dysfunction after trauma and surgery: a prospective cohort study

We have developed a two-step procedure for preparing the skin before peripheral venous catheter (PVC) insertions. This procedure involves two successive swabbings with wipes soaked in alcoholic antiseptic. We investigated whether this two-step procedure was as effective and safe as the standard four-step procedure – washing with detergent, rinsing, drying, applying antiseptic – by carrying out a multicentre randomised equivalence study comparing the frequency of precursor signs of infection at the site of insertion for the two skin preparation procedures. The study was carried out over an eight-month period, and 248 PVC insertion sites were evaluated. The two-step procedure was used for 130 subjects and the standard procedure for 118. Taking into account all the confounding factors predisposing patients to the complications studied, the characteristics of the two groups of patients were found to be similar, with no significant differences noted. The incidence of precursor signs of infection was 11 % 24 hours after PVC insertion (27/248), 25 % at 48 hours (50/203) and at 29 % at 72 hours (34/119). Eleven patients had complications necessitating the withdrawal of the PVC: sensitivity of the insertion site, with redness and/or slight swelling and/or a palpable venous cord. No major complications were observed in this study. The frequency of local complications associated with PVCs reported in this study, whether simple or severe, was not affected by the skin preparation procedure used for PVC insertion (two-step or four-step procedure).     

Prevention of infection in voluntary surgical contraception

The prevention of infections requires serious attention from personnel of voluntary surgical contraception programs. Preoperative antisepsis of the skin, use of careful surgical handwashing, sterilization of high-level disinfection of surgical equipment, and meticulous surgical technique are essential to prevent the occurrence of all types of infection. Screening clients for pre-existing infection, especially tubal infection, is important. Preferred antiseptics for both the surgical scrub and skin preparation of the patient are iodophors such as Betadine and chlorhexidine preparation such as Hibitane. Also effective are hexochlorophene (e.g., pHisoHex) for the surgical scrub and tincture of iodine for the operative site. Thorough cleaning and steam autoclaving to sterilize heat stable items and glutaraldehyde soaking to disinfect laparoscopes have become accepted standards. Small incisions, careful nontraumatic tissue handling, and excellent hemostasis all contribute to reduce infection risks. If unsuspected active pelvic infection is encountered at the time of minilaparotomy or laparoscopy, the tubes should not be occluded. Clients undergoing surgical sterilization should be instructed in how to care for their incision, what side effects to expect, when to resume normal activity, and what to do if complications develop. Clients must understand the importance of seeking immediate medical care if the incision becomes inflamed or tender, if there is bleeding, or if fever develops. Good follow up and reporting of infections will also produce data that can identify programs with excessive rates of poststerilization infection so that remedial measures can be taken.     

Efficacy of two ethanol-based skin antiseptics on the forehead at shorter application times

Background  

Recent research suggests that alcohol-based skin antiseptics exhibit their efficacy on the resident skin flora of the forehead in less than 10 minutes. That is why we have looked at the efficacy of two ethanol-based skin antiseptics applied for 10, 2.5 and 2 minutes on skin with a high density of sebaceous glands. Each experiment was performed in a reference-controlled cross-over design with at least 20 participants. Application of isopropanol (70%, v/v) for 10 minutes to the forehead served as the reference treatment. The clear (skin antiseptic A) and coloured preparations (skin antiseptic B) contain 85% ethanol (w/w). Pre-values and post-values (immediately after the application and after 30 min) were obtained by swabbing a marked area of 5 cm² for about 10 s. Swabs were vortexed in tryptic soy broth containing valid neutralizing agents. After serial dilution aliquots were spread on tryptic soy agar. Colonies were counted after incubation of plates at 36°C for 48 h. The mean log₁₀ reduction of bacteria was calculated. The Wilcoxon matched-pairs signed-ranks test was used for a comparison of treatments.     

Skin Preparation for the Prevention of Surgical Site Infection: Which Agent Is Best?

Procedural and surgical site infections create difficult and complex clinical scenarios. A source for pathogens is often thought to be the skin surface, making skin preparation at the time of the procedure critical. The most common skin preparation agents used today include products containing iodophors or chlorhexidine gluconate. Agents are further classified by whether they are aqueous-based or alcohol-based solutions. Traditional aqueous-based iodophors, such as povidone-iodine, are one of the few products that can be safely used on mucous membrane surfaces. Alcohol-based solutions are quick, sustained, and durable, with broader spectrum antimicrobial activity. These agents seem ideal for longer open surgeries with the potential for irrigation or surgical spillage, such as cystoprostatectomy, radical prostatectomy, and retroperitoneal lymph node dissection.Key words: Skin pathogens, Procedural and surgical site infection, Skin preparation solutionsSurgical site infection (SSI) complicates an estimated 5% of all clean-contaminated operations performed annually in US hospitals and accounts for the most common nosocomial infection in surgical patients.¹ Patients who develop SSI have longer and costlier hospitalizations and are more likely to spend time in an intensive care unit (ICU), are 5 times more likely to be readmitted, and are twice as likely to die.²Recognizing this substantial morbidity and economic burden, in 1999 the Centers for Disease Control (CDC) issued standardized guidelines for the prevention of surgical infections. These included making specific evidence-based recommendations for modifying patient factors that may predispose to infection, for the use of antimicrobial prophylaxis, for optimizing sterility in the operating room, and for the use of antiseptic agents for skin preparation.The choice of which specific agent to use for skin preparation was not addressed due to the diversity of sites and approaches in surgery, as well as the absence of data on SSI risk in well-controlled, operation-specific studies.¹ Therefore, the choice of agent should be based primarily on the surgeon’s knowledge of the product’s efficacy, cost, and ease of use. Urologic surgeons have the additional challenge of choosing the best agent for the variety of procedures that they perform, including intraperitoneal and extraperitoneal surgery; scrotal, perineal, and vaginal operations; endoscopy; and percutaneous renal surgery. Each of these operative sites has different endogenous flora, body contours, and skin types, all factors that influence the risk of SSI and, therefore, the best type of antiseptic skin agent to use. This article focuses on skin preparation for the prevention of SSI with an assessment of currently available antiseptic products and their application to urologic surgery.     

Evaluation of a cup scrub technique for quantification of the microbial flora on bovine skin

A cup-scrub technique devised for sampling the human skin surface microflora was evaluated in cattle. Scrub samples from bovine skin contained clumps of squama and bacterial microcolonies which were progressively broken down by shaking. This was accelerated in the presence of ballotini beads but aggregations of bacteria were still present after prolonged agitation. Vigorous shaking, particularly with beads, decreased the viability of the bacteria and optimum viable counts were obtained after manual shaking for half a minute. Immersion in buffered detergent, wash and diluting fluids for up to 2 h promoted release of bacteria from microcolonies but decreased the viability of aerobic and anaerobic pleomorphic rods and a Bacillus strain. There was no significant effect on strains of Micrococcaceae. Prolonged exposure of bacteria from scrub samples to these fluids can thus lead to both quantitative and qualitative alterations in the counts obtained, although these effects may be masked by the continuing release of bacteria from microcolonies. The cup-scrub technique provides a convenient means of quantifying changes in the bovine skin microflora but results obtained from different studies should only be compared if closely similar techniques are used.     

A high throughput substrate binding assay reveals hexachlorophene as an inhibitor of the ER-resident HSP70 chaperone GRP78

Glucose-regulated protein 78 (GRP78) is the ER resident 70 kDa heat shock protein 70 (HSP70) and has been hypothesized to be a therapeutic target for various forms of cancer due to its role in mitigating proteotoxic stress in the ER, its elevated expression in some cancers, and the correlation between high levels for GRP78 and a poor prognosis. Herein we report the development and use of a high throughput fluorescence polarization-based peptide binding assay as an initial step toward the discovery and development of GRP78 inhibitors. This assay was used in a pilot screen to discover the anti-infective agent, hexachlorophene, as an inhibitor of GRP78. Through biochemical characterization we show that hexachlorophene is a competitive inhibitor of the GRP78-peptide interaction. Biological investigations showed that this molecule induces the unfolded protein response, induces autophagy, and leads to apoptosis in a colon carcinoma cell model, which is known to be sensitive to GRP78 inhibition.     

Rapid preparation of a noncultured skin cell suspension that promotes wound healing

Autologous skin cell suspensions have been used for wound healing in patients with burns and against normal pigmentation in vitiligo. To separate cells and the extracellular matrix from skin tissue, most researchers use enzymatic digestion. Therefore, this process is difficult to perform during a routine surgical procedure. We aimed to prepare a suspension of noncultured autologous skin cells (NCSCs) using a tissue homogenizer as a new method instead of harsh biochemical reagents. The potential clinical applicability of NCSCs was analyzed using a nude-rat model of burn healing. After optimization of the homogenizer settings, cell viability ranged from 52 to 89%. Scanning electron microscopy showed evidence of keratinocyte-like cell morphology, and several growth factors, including epidermal growth factor and basic fibroblast growth factor, were present in the NCSCs. The rat model revealed that NCSCs accelerated skin regeneration. NCSCs could be generated using a tissue homogenizer for enhancement of wound healing in vivo. In the NCSC group of wounds, on day 7 of epithelialization, granulation was observed, whereas on day 14, there was a significant increase in skin adnexa regeneration as compared to the control group (PBS treatment; p < 0.05). This study suggests that the proposed process is rapid and does not require the use of biochemical agents. Thus, we recommend a combination of surgical treatment with the new therapy for a burn as an effective method.     

Antimicrobial Actions of Hexachlorophene: Cytological Manifestations

Hexachlorophene is a soap-compatible bisphenol that has been widely used as an antiseptic, yet its mechanism of action is undefined. The relative threshold concentration for bactericidal effect on a susceptible test organism, Bacillus megaterium, was established to be about 10 mug/mg of cell dry weight. At this or at high (>/=100 mug/mg) concentration, adsorptive uptake by cells displayed saturation kinetics. At about 30 mug/mg, the time course of adsorption occurred in three distinct stages. The triphasic pattern was interpreted to represent successive penetration of and adsorption by the cell wall, the protoplast membrane, and the cytoplasm. This interpretation was substantiated by determinations of hexachlorophene adsorption by isolated cell components. Electron microscopy disclosed cytopathology, evidenced as gaps or discontinuities, in the protoplast membrane (but not in the cell wall or cytoplasm) at > 30 mug of hexachlorophene per mg of cell dry weight. Similarly, treatment with > 30 mug/mg allowed a fluorescigenic dye (tolyl-peri acid) to penetrate into the protoplast. However, no detectable cytological manifestations were discerned at the minimum lethal concentration of 10 mug/mg. Apparently, hexachlorophene is physically disruptive at intermediate or high relative concentrations but acts in a more subtle fashion at the minimal lethal concentration.     

Antimicrobial Actions of Hexachlorophene: Release of Cytoplasmic Materials

Intracellular solutes were released from growing or resting cells of Bacillus megaterium as a consequence of hexachlorophene treatment. The effect was dose dependent, with the optimum at a concentration about sevenfold greater than the minimal lethal dose. The effects of pH and temperature on the leakage process also were inconsistent with the killing effects of the drug. The types of materials released appeared to be the same with or without hexachlorophene treatment. The released materials were small molecules which apparently derived from preexisting ribonucleic acid and protein, but not from deoxyribonucleic acid. Compared to the effects of other representative surface-active agents and other bis-phenols, hexachlorophene was superior in ability to cause leakage of intracellular materials. Different microorganisms varied in their susceptibility to hexachlorophene, with Pseudomonas aeruginosa and a paracolon isolate the most resistant of the vegetative cells examined. It was concluded that the release of intracellular solutes was an effect secondary to the lethal event and presumably arose from hexachlorophene-mediated stimulation of degradative enzymes.     

Combined antibacterial effects of tissue‐tolerable plasma and a modern conventional liquid antiseptic on chronic wound treatment

Potential antimicrobial effects of sequential applications of tissue‐tolerable plasma (TTP) and the conventional liquid antiseptic octenidine dihydrochloride (ODC) were investigated. 34 patients with chronic leg ulcers were treated with TTP, ODC or a combination of both. The bacterial colonization was measured semi‐quantitatively before and immediately after treatment and changes in the microbial strains' compositions before and after antiseptic treatments were analyzed. All antiseptic procedures reduced the bacterial counts significantly. The sequential application of TTP and ODC displayed the highest antimicrobial efficacy. Me combined use of TTP and conventional antiseptics might represent the most efficient strategy for antiseptic treatment of chronic wounds. (© 2014 WILEY‐VCH Verlag GmbH &Co. KGaA, Weinheim)     

Comparison of two skin antiseptics in blood transfusion. Comparison with the results of the bacteriologic control of labile blood products

The comparison of two skin antiseptics (70 degrees alcohol and 0,5% alcoholic chlorhexidine solution) was carried out by the method of in vivo impressions. The study used 45 healthy volonteers from whom a bacteriological sample was taken from both bends of the elbow, without use of an antiseptic, and after the application of one according to usual sample taking methods. The subjects were divided into two sets according to the antiseptic being tested. The results of the cultures after 24 and 48 hours are expressed in the number of germs per cm2, which thus permits us to calculate a reduction in percentage or log 10 form, and to appreciate the efficiency of the antiseptic studied. Routine bacteriological inspection of labile blood products was carried out on products picked at random every week during 18 months of exclusive use of 70 degrees alcohol by the sample taking services. The results show a comparable in vivo effectiveness of the two antiseptics on the superficial aerobic flora of the bend of the elbow, and the ease of use of 70 degrees alcohol has led to its choice. This choice is confronted with the results of the inspection of blood products: out of 1 293 inspections, only one slight contamination (cocci gram+) was found on a unit of whole blood. These data as a whole can be compared with the work of various authors.     

Effect of antimicrobial soap containing chlorhexidine on the microbial flora of skin.

The qualitative and semiquantitative changes in the aerobic microbial flora of normal skin with the prolonged use of a chlorhexidine scrub (6 months) were investigated. More samples in the chlorhexidine scrub group had gram-negative bacilli in their axilla (63 of 96, 66%) and groin (36 of 96, 38%) than the controls (32 of 66, 49%, for axilla and 7 of 66, 11%, for groin; P = 0.01). Klebsiella and Enterobacter were the predominant organisms in the control and chlorhexidine groups, respectively. The chlorhexidine scrub produced a reduction in the total aerobic counts in the axilla, groin, and between the toes and the fingers. Fewer samples from the chlorhexidine-treated areas revealed the presence of lipophilic diphtheroids than did the controls. Lipophilic diphteroids were also reduced quantitatively in the groin and axilla with chlorhexidine treatment. No consistent pattern for the other major groups of bacteria was noted between the treatments.     

Effects of habitat,season, and age on winter fat storage by migrant and resident birds in Jamaica

Most small birds wintering in the tropics should show little subcutaneous fat deposition (SFD), except in habitats where food availability may decline in late winter or, for some resident species, to prepare for incubation or brooding fasts. However, these predictions need re‐examination in light of a new, precise, cross‐validated method to compare SFD among habitats and species. We sampled 170 Nearctic‐Neotropical migrant and 279 resident birds during early and late winter in 1993 and 1994 in Jamaica, West Indies. Habitats, from greatest to least expected availability of insect prey, were (1) mangrove forest, (2) montane/foothills forest and cultivation, (3) dry limestone forest, and (4) acacia scrub. Percent lipid, estimated from multiple‐regression models using visual fat scoring (0–8 scale), total‐body electrical conductivity, and a variety of morphometrics, was categorized by percentile ranks to determine if SFD varied by habitat, season, or age for all species, resident species, migrant species, and several individual species. SFD averaged ~ 13% total mass for all birds, ranging from 8–24% for well‐sampled species. The few bird species in acacia scrub, primarily two facultative long‐distance migrants, averaged ~ 26% lipid content, significantly more than birds in other habitats. Most birds did not vary in SFD in the other three habitats, although Common Yellowthroats (Geothlypis trichas) had greater SFD in dry limestone habitat than in montane habitat. Bananaquits (Coereba flaveola) and Jamaican Euphonias (Euphonia jamaica) in montane habitat, especially in early winter, had higher SFD than other resident species. Contrary to our prediction, adults and juveniles had similar SFD, with the exception of juveniles having more SFD than adults in acacia scrub habitat. Winter fat deposition (or, in some cases, muscle‐protein catabolism) in the tropics may be an overlooked strategy, potentially important as a hedge against fasting for floaters, facultative migrants, some territorial migrants in habitats with seasonal declines in food resources, and some resident species prior to breeding.