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Z Orthop Unfall 2018; 156(05): 567-573
DOI: 10.1055/a-0608-5292
Originalarbeit
Georg Thieme Verlag KG Stuttgart · New York

The Effect of Antiseptics in the Prophylaxis of Infection in Orthopaedic Surgery

Results of a Systematic ReviewEffekt topischer Antiseptika zur Prophylaxe periprothetischer Infektionen?
Martin Lüdemann
1   Orthopaedic Department, König-Ludwig-Haus, University of Würzburg
,
Pablo Munoz
1   Orthopaedic Department, König-Ludwig-Haus, University of Würzburg
,
Martin Wagner
2   Institute of Clinical Epidemiology and Biometry, University of Würzburg
,
Uwe Malzahn
3   Clinical-Trial-Center, Julius-Maximilians-Universität Würzburg
,
Konstantin Horas
1   Orthopaedic Department, König-Ludwig-Haus, University of Würzburg
,
Peter Heuschmann
2   Institute of Clinical Epidemiology and Biometry, University of Würzburg
,
Maximilian Rudert
1   Orthopaedic Department, König-Ludwig-Haus, University of Würzburg
› Author Affiliations
Further Information

Publication History

Publication Date:
14 June 2018 (online)

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Abstract

Introduction Over the past decade, the incidence of revision arthroplasty has increased substantially. One of the main reasons for revision arthroplasty is periprosthetic joint infection, often resulting in multiple surgical interventions with variable success and poor clinical outcome. Intraoperative wound irrigation has been proposed to reduce bacterial contamination and thus the risk of periprosthetic infection. However, there is currently no widely accepted recommendation for the use of topical antiseptics within the operative setting for primary implantation. We performed a systematic review of studies pertaining to the use of intraoperative topical antiseptics and their effectiveness in preventing infection of orthopaedic implants.

Materials and Methods A comprehensive literature search including MEDLINE (PubMed), Cochrane Library, and Current Contents Medicine (CCMED-Medpilot) was performed according to a standardised protocol.

Results Overall, 1905 articles were initially assessed. Four studies met the inclusion criteria and remained for further analysis, comprising two prospective cohort studies using retrospective control groups (evidence level II – III) and two randomised controlled trials (evidence level I). 0.35% Povidone-iodine (PVP-I) was used in three of these studies and a solution of 6.25% PVP-I and 6.25%-hydrogen peroxide (H2O2) in one study for intraoperative wound irrigation. There was a clear trend in all studies suggesting that intraoperative topical antiseptics are effective in preventing periprosthetic infection.

Conclusion Although no clear regimen can be recommended, the available literature indicates that the use of intraoperative topical antiseptics is of clinical relevance in preventing infection of orthopaedic implants. Further randomised controlled trials are recommended.

Zusammenfassung

Hintergrund Trotz steigender Revisionsoperationen nach Hüft- und Knie-TEP-Implantationen, dadurch zunehmenden Kosten für das Gesundheitswesen und häufiger auftretenden multiresistenten Bakterien ist zur prophylaktischen intraoperativen Anwendung topischer Antiseptika zur Verhinderung periprothetischer Infektionen wenig bekannt. Ziel dieser Studie ist die Suche und statistische Aufarbeitung (Metaanalyse) existierender Studien über die Wirksamkeit und Sicherheit intraoperativ-prophylaktischer Antiseptika-Spülungen nicht infizierter Wunden während endoprothetischer Operationen.

Material und Methode Hierzu erfolgte eine umfassende Literaturrecherche als elektronische Suche nach festem Protokoll über MEDLINE (PubMed), Cochrane Library und Current Contents Medicine (CCMED-Medpilot).

Ergebnisse insgesamt wurden zunächst 1905 erfasst, nach Anwendung des Protokolls mit Ein- und Ausschlusskriterien blieben nur 4 relevante Studien. Zwei dieser eingeschlossenen Studien sind prospektive Kohortenstudien mit retrospektiver Kontrollgruppe mit Evidenzlevel II bis III. Die 2 weiteren Studien sind randomisierte kontrollierte Studien mit Evidenzlevel I. Drei der 4 Studien untersuchten PVP-Iod als Antiseptikum zur intraoperativen Wundspülung, wohingegen die vierte Studie ein Gemisch aus PVP-Iod und H2O2 verwendete. Keiner der Studien beinhaltet eine Placebo-Kontrolle. Alle 4 Untersuchungen zeigen insgesamt einen klaren Trend, der die prophylaktische Wirkung lokaler topischer Antiseptika zur Vermeidung periprothetischer Infektionen hervorhebt.

Schlussfolgerung Lokal topische Antiseptika könnten eine wichtige Bedeutung in der Behandlung und Prophylaxe periprothetischer Infektionen erlangen. Weitere „well designed random controlled“ Studien, besonders unter Einbeziehung geeignet erscheinender Antiseptika mit günstigem Biokompatibilitäts-Index wie Octenidin oder Polihexanid sind notwendig.

Key words

periprosthetic infection - prophylaxis - topical irrigation - intraoperative wound irrigation - antiseptics

Schlüsselwörter

periprothetische Infektion - Prophylaxe - intraoperative Wundspülung - topische Spülung - Antiseptika
 

  • References

  • 1 AQUA-Institute GmbH. Institute for Applied Quality Improvement and Research in Health Care 2015. Available at: https://www.aquainstitut.de/projekte/qualitaetsreport online 2015
    PubMedGoogle Scholar
  • 2 Parvizi J, McKenzie JC, Cashman JP. Diagnosis of periprosthetic joint infection using synovial C-reactive protein. J Arthroplasty 2012; 27: 12-16
    CrossrefPubMedGoogle Scholar
  • 3 Friesecke C, Wodtke J. Management of periprosthetic infection. Chirurg 2008; 79: 793-794
    PubMedGoogle Scholar
  • 4 Darouiche R, Mosier M, Voigt J. Antibiotics and antiseptics for preventing infection in people receiving primary total joint prostheses. Cochrane Database Syst Rev 2015; DOI: 10.1002/14651858.CD010363.
    PubMedGoogle Scholar
  • 5 Kurtz SM, Lau E, Schmier J. et al. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty 2008; 23: 984-991
    CrossrefPubMedGoogle Scholar
  • 6 McGarry SA, Engemann JJ, Schmader K. et al. Surgical-site infection due to Staphylococcus aureus among elderly patients: mortality, duration of hospitalization, and cost. Infect Control Hosp Epidemiol 2004; 25: 461-467
    CrossrefPubMedGoogle Scholar
  • 7 World Health Organization. Antimicrobial resistance: global report on surveillance 2014. Available at: http://www.who.int/mediacentre/factsheets/fs194/en updated: November 2017; online November 2017
    PubMedGoogle Scholar
  • 8 Kramer A, Daeschlein G, Kammerlander G. et al. Konsensusempfehlung zur Auswahl von Wirkstoffen für die Wundantiseptik. ZFW 2004; 3: 110-120
    PubMedGoogle Scholar
  • 9 Högele AM, Neu J. Wound closure after irrigation with Octenisept® without possibility for drainage. Unfallchirurg 2011; 114: 70-72
    CrossrefPubMedGoogle Scholar
  • 10 Bundesgesundheitsblatt. Prävention postoperativer Infektionen im Operationsgebiet. Bundesgesundheitsbl 2007; 50: 377-393 doi:10.1007/s00103-007-0167-0
    CrossrefPubMedGoogle Scholar
  • 11 Higgins J, Altmann DG. Cochrane Handbook for systematic Reviews of Interventions. Version 5.1.0. The Cochrane Collaboration. Hoboken, NJ, USA: Wiley Online Library, John Wiley & Sons; 2011
    Google Scholar
  • 12 NHS – National Health Service – Centre for Reviews and Dissemination, University of York, UK. Systematic reviews. Available at: http://www.york.ac.uk/media/crd/Systematic_Reviews.pdf updated: January 2009; online January 2009
    PubMedGoogle Scholar
  • 13 Chang FY, Chang MC, Wang ST. et al. Can povidone-iodine solution be used safely in a spinal surgery?. Eur Spine J 2006; 15: 1005-1014
    CrossrefPubMedGoogle Scholar
  • 14 Cheng TM, Chang MC, Wang ST. et al. Efficiacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976) 2005; 30: 1689-1693
    CrossrefPubMedGoogle Scholar
  • 15 Brown NM, Cipriano CA, Moric M. et al. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012; 27: 27-30
    CrossrefPubMedGoogle Scholar
  • 16 Ulivieri S, Toninelli S, Petrini C. et al. Prevention of post-operative infections in spine surgery by wound irrigation with a solution of povidone-iodine and hydrogen peroxide. Arch Orthop Trauma Surg 2011; 131: 1203-1206
    CrossrefPubMedGoogle Scholar
  • 17 Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: an evidence-based review. Can J Surg 2007; 50: 473-481
    PubMedGoogle Scholar
  • 18 Kramer A, Assadian O, Below H, Willy C. Wound Antiseptics today – an Overview. In: Willy C. ed. Antiseptics in Surgery. Berlin: Book Publishing; 2013: 83-110
    Google Scholar
  • 19 Aiba M, Ninomiya J, Furuya K. et al. Induction of a critical elevation of povidone-iodine absorption in the treatment of a burn patient: report of a case. Surg Today 1999; 29: 157-159
    CrossrefPubMedGoogle Scholar
  • 20 Kovacikova L, Kunovsky P, Skrak P. et al. Thyroid hormone metabolism in pediatric cardiac patients treated by continuous povidone-iodine irrigation for deep sternal wound infection. Eur J Cardiothorac Surg 2002; 21: 1037-1041
    CrossrefPubMedGoogle Scholar
  • 21 Fleischer W, Reimer K. Povidone-iodine in antisepsis – state of the art. Dermatology 1997; 195: 3-9
    CrossrefPubMedGoogle Scholar
  • 22 Reimer K, Wichelhaus TA, Schäfer V. et al. Antimicrobial effectiveness of povidone-iodine and consequences for new application areas. Dermatology 2002; 204 (Suppl. 01) 114-120
    CrossrefPubMedGoogle Scholar
  • 23 Block C, Robenshtok E, Simhon A. et al. Evaluation of chlorhexidine and povidone iodine activity against methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis using a surface test. J Hosp Infect 2000; 46: 147-152
    CrossrefPubMedGoogle Scholar
  • 24 Reimer K. Molecular effects of a microbicidal substance on relevant microorganisms: electron microscopic and biochemical studies on povidone-iodine. Zentralbl Hyg Umweltmed 1998; 200: 423-434
    PubMedGoogle Scholar
  • 25 Burks RI. Povidone-iodine solution in wound treatment. Phys Ther 1998; 78: 212-218
    CrossrefPubMedGoogle Scholar
  • 26 Kaysinger KK, Nicholson NC, Ramp WK. et al. Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. J Orthop Trauma 1995; 9: 303-311
    CrossrefPubMedGoogle Scholar
  • 27 Kawana R, Kitamura T, Nakagomi O. et al. Inactivation of human viruses by povidone-iodine in comparison with other antiseptics. Dermatology 1997; 195 (Suppl. 02) 29-35
    PubMedGoogle Scholar
  • 28 Kramer A, Below H, Behrens-Baumann W. et al. New aspects of the tolerance of the antiseptic povidone-iodine in different ex vivo models. Dermatology 2002; 204 (Suppl. 01) 86-91
    PubMedGoogle Scholar
  • 29 Müller G, Kramer A. Comparative study of in vitro cytotoxicity of povidone-iodine in solution, in ointment or in a liposomal formulation (Repithel) and selected antiseptics. Dermatology 2006; 212 (Suppl. 01) 91-93
    CrossrefPubMedGoogle Scholar
  • 30 König B, Reimer K, Fleischer W. et al. Effects of Betaisodona on parameters of host defense. Dermatology 1997; 195 (Suppl. 02) 42-48
    CrossrefPubMedGoogle Scholar
  • 31 Moore K, Thomas A, Harding KG. Iodine released from the wound dressing Iodosorb modulates the secretion of cytokines by human macrophages responding to bacterial lipopolysaccharide. Int J Biochem Cell Biol 1997; 29: 163-171
    CrossrefPubMedGoogle Scholar
  • 32 Fumal I, Braham C, Paquet P. et al. The beneficial toxicity paradox of antimicrobials in leg ulcer healing impaired by a polymicrobial flora: a proof of-concept study. Dermatology 2002; 204 (Suppl. 01) 70-74
    CrossrefPubMedGoogle Scholar
  • 33 Daróczy JL. Quality control in chronic wound management: the role of local povidone-iodine (Betadine) therapy. Dermatology 2006; 212 (Suppl. 01) 82-87
    PubMedGoogle Scholar
  • 34 Pitten FA, Werner HP, Kramer A. A standardized test to assess the impact of different organic challenges on the antimicrobial activity of antiseptics. J Hosp Infect 2003; 55: 108-115
    CrossrefPubMedGoogle Scholar
  • 35 Kramer A, Hübner NO. Wundspülung und Wundantiseptik. Akt Dermatol 2008; 34: 392-395
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Kunisada T, Yamada K, Oda S. et al. Investigation on the efficacy of povidone-iodine against antiseptic-resistant species. Dermatology 1997; 195 (Suppl. 02) 14-18
    CrossrefPubMedGoogle Scholar
  • 37 Vörös P, Dobrindt O, Perka C. et al. Human osteoblast damage after antiseptic treatment. Int Orthop 2014; 38: 177-182
    CrossrefPubMedGoogle Scholar
  • 38 Roth B, Assadian O, Wurmitzer F. et al. Wundinfektionen nach antiseptischer Primärversorgung kontaminierter traumatischer Wunden mit Polihexanid, PVP-Iod bzw. Wasserstoffperoxid. GMS Krankenhaushyg Interdiszip 2007; 2: Doc58
    PubMedGoogle Scholar
  • 39 Hirsch T, Koerber A, Jacobsen F. et al. Evaluation of toxic side effects of clinically used skin antiseptics in vitro. J Surg Res 2010; 164: 344-350
    CrossrefPubMedGoogle Scholar
  • 40 Müller G, Kramer A. Biocompatibility index of antiseptic agents by parallel assessment of antimicrobial activity and cellular cytotoxicity. J Antimicrob Chemother 2008; 61: 1281-1287
    CrossrefPubMedGoogle Scholar