Breaking the circle of antibiotic resistance
Could pre-surgery wash be a magic bullet in the fight against infections and antibiotic-resistant pathogens? One current approach is to specifically screen all patients for MRSA, a huge effort and drain on resources. A pre-surgery body wash could be the key to optimize the process: One study indicated that this whole-body wash used to universally decolonize patients before surgery may be just as effective as the targeted approach, both clinically and economically.
The wash breaks the vicious circle of antibiotic resistance by minimizing staphylococcus, staving off infections that would otherwise require antibiotic treatment and thereby decreasing the risk of antibiotic resistance. But let's take it from the top.
MDRO, MRSA, SSI: What are we talking about?
MDRO = “multidrug-resistant organisms”
Most types of bacteria can be treated with antibiotics. Over time, some bacteria may become resistant to certain antibiotics, making the infections more difficult to treat. For most patients, other effective antibiotics are still available as alternative treatment, but bacterial infections resistant to all known antibiotics are becoming more common.
All MDRO can lead to serious infections of wounds, lungs, urinary tract, and blood stream. They most commonly affect immunocompromised patients or those with in-dwelling medical devices, can easily be transferred amongst patients and are known to be difficult to treat. Apart from the physical consequences, they can add a psychological burden through infection prevention measures such as patient isolation and contact precautions 1.
Of all MDRO, S. aureus is one of the most common pathogens in health care facilities and can cause a wide range of infections, sepsis and death 2. S. aureus is also the leading pathogen causing SSI 3. The CDC have qualified MRSA as a “serious threat” 4.
SSI = surgical site infections
In health care facilities such as hospitals, the operating room is obviously a particular point of concern: Patients are often very ill and any open wound is of course an ideal point of entry for a pathogen. S. aureus is the predominant organism causing surgical site infections (SSI), which affect up to 20 percent of surgical patients 5, 6. SSI pathogens frequently develop resistance against a wide range of clinically important antibiotics.
The World Bank has issued an alert that infections caused by MDRO could induce an economic damage equal to the financial crisis year of 2008 7.
Which solutions are available?
General measures against MDRO/MRSA
Obviously, different countries, regions or hospitals may have their own set of rules and regulations to prevent and combat MRSA. However, in general the following recommendations have emerged:
- Should be educated about MDRO, MRSA, SSI and their role to prevent these infections, e.g. by using a pre-surgery body wash.
- Should be screened for MRSA 8. This “targeted decolonization” is effective in reducing MRSA infections, but also involves huge logistical efforts: Patients have to be screened, the samples have to be sent off to the (possibly external) lab, results have to be awaited; positive outpatients have to be rescheduled for surgery, positive inpatients need to be isolated.
- The hospital ‘Infection Prevention and Control Team’ (IPCT) should evaluate and advise.
- Should perform washing / decolonization in accordance with guidelines.
- Step into the details of the guidelines for the prevention of SSI including pre-surgery body wash.
These measures can be effective in reducing MRSA infection rates, even in European countries with high prevalence settings 9. A recent systemic review of 83 studies on measures to prevent MRSA infections – screening of patients, decolonization of nasal MRSA, isolation in single rooms – concluded that there is no “one size fits all” recommendation. Indeed, it might be less a single measure and more a bundle of measures that could be effective.
Universal decolonization with Polyhexanide
Apart from these general measures against MDRO, there are also more specific recommendations on how to reduce SSI in the phases before, during and after surgery (pre-, intra- and postoperative setting). And this is where the pre-surgery body wash comes in.
Preoperative bathing and decolonization of the nose and skin with a pre-surgery body wash are key recommendations to reduce SSI. The Gold Standard products used for this purpose are chlorhexidine and mupirocin; in some countries, octenidine is seen as an option. However, rising rates of resistance have been observed against all three products (e.g. in S. aureus), raising concerns and increasing the call for alternative decolonization molecules 10. In addition, chlorhexidine is associated with a range of adverse reactions, from mild irritant contact dermatitis to life-threatening anaphylaxis.
Polyhexanide was rated as excellent alternative candidate, with no reports of severe adverse reactions or bacterial resistance. Studies have shown that decolonization treatment of MRSA infections with polyhexanide does not reduce polyhexanide susceptibility or lead to chlorhexidine cross-resistance 11. And one paper investigating the economic impact of a universal decolonization process vs. the ‘targeted screening and selective treatment’ of arthroplasty patients at the Washington University School of Medicine found the universal approach to save costs of 717,205US$ over 25 months 12. It therefore seems safe to assume that similar effects would also be seen with the polyhexanide body wash Prontoderm®, a body wash that has been investigated in numerous studies.
One pivotal paper investigated the effect of a universal decolonization with Prontoderm® on the SSI rate of hip and knee arthroplasties 13.
The main results are:
- After implementation of the body wash, initial SSI rates due to S. aureus decreased from 0.24/100s surgeries to 0.05/100 surgeries.
- Polyhexanide is a safe antiseptic substance and an alternative to chlorhexidine and mupirocin.
- Universal preoperative decolonization is an effective strategy to reduce S. aureus SSI.
- Universal preoperative decolonization appears to be more cost-effective than the costly and cumbersome targeted decolonization.
Effective against Multi-DrugResistant-Organisms (MDRO) such as MRSA, VRE, ESBL Prontoderm® - for MDRO decolonization of skin and mucous membranes through physical cleansing
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What to expect from the training?
Experience our interactive training which prescribes the germ-reducing body wash for patients as an effective weapon against MRSA & Co.
"Universal preventive body washing & and preoperative universal decolonisation"
Even though the causes of surgical site infections (SSI) are widely known, these infections remain an unsolved problem in the medical world. Mistakes still commonly happen along the treatment pathway – before, during and after surgery. They do however not happen due to a lack of knowledge or care but rather due to the stress and complexity of the OR environment. As part of a bundle approach for the prevention of SSI, universal decolonization with polyhexanide can contribute to reduced SSI rates.
Learn more about MDRO's and the danger of surgical site infections and get insights how to prevent these. It will take you approx. 20 min. to work through the contents of the training.
After proceeding the training you'll receive a certificate via eMail.
Register now for the training:
(last access June 2021)
1. Datta R et al. Burden and Management of Multidrug-Resistant Organisms in Palliative Care. Palliat Care 2017; doi: 10.1177/11782242177492333.
2. Hassoun A et al. Incidence, prevalence, and management of MRSA bacteremia across patient populations – a review of recent developments in MRSA management and treatment. Crit Care 2017;21:211.
3. Weiner lM et al. Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections : Summary of Data Reported to the National Healthcare Safety Network ant the Centers for Disease Control and Prevention, 2011-2014. Infect Control Hosp Epidemiol 2016;37(11):1288-1301.
5. 2016 J. Pochhammer et al. Vermeidung postoperativer Wundinfektionen, Allgemein- und Viszeralchirurgie, Krankenhaushygiene up2date.
6. Gottrup F. Prevention of surgical-wound infections. NEJM 2000 ;342:202-204.
9. Köck R et al. Systematic literature analysis and review of targeted preventive measures to limit healthcare-associated infections by methicillin-resistant Staphylococcus aureus. Euro Surveill. 2014;19(29):pii=20860.
10. Hardy K et al. Increased usage of Antiseptics is Associated with Reduced Susceptibility in Clinical Isolates of Staphylococcus aureus. mBIO 2018;9:e00894-18.
11. Renzoni A et al. Impact of Exposure of Methicillin-Resistant Staphylococcus aureus to Polyhexanide In Vitro and In Vivo. Antimicrob Agents Chemother 2017;61:e00272-17.
12. Stambough JB et al. Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty. Journal of Arthroplasty 2017;32:728-734.
13. Wandhoff B et al. Efficacy of universal preoperative decolonization with Polyhexanide in primary joint arthroplasty on surgical site infections. A multicenter before-and-after-study. ARIC-Journal 2020;8:188; https://doi.org/10.1186/s13756-020-00852-0