翻译：周超群   审核：陈志锦

（SIFIC热点团队）

—— PDI医疗临床科学联络员Fran Canty

患者备皮产品的选择基于多个因素，包括：患者的过敏与敏感性、患者的年龄、手术的位置与类型、手术部位体液与血液暴露的预期量以及外科医生偏好等。除了上述的评估以外，备皮消毒剂的选择还应考虑以下几点：易于应用、皮肤上的细菌定植能力、血液和盐水冲击下的有效性、覆盖面积和每例手术准备的成本效益。

——3M感染预防部技术服务专家Kimberly Prinsen，RN，MSN

无论是加速皮肤脱屑的移植物抗宿主病或失禁相关性皮炎等患者，还是斯蒂芬·约翰逊综合征患者与严重肥胖症相关真菌性皮炎患者，其皮肤的不完整都将会引起备皮风险的增加，对备皮来说都是重大难题，因为足以控制细菌或真菌感染的产品具有腐蚀性，并易引起细胞毒性反应。

——Avadim科技首席执行官Steve Woody

患者、产品、程序和制度等因素均对备皮产品产品的使用发起挑战。患者的常规卫生可能需要额外的保护措施，例如患者的一般清洁或脱毛作为备皮开始之前的必要措施。患者周转指标与备皮消毒剂制造商使用说明存在时间冲突，虽然不是不可能，但由于不同产品的说明书可能有所不同，所以执行起来很困难。其中一些产品不仅增加了患者备皮的总时间，而且引入了过度稀释或交叉污染的风险，这也是FDA在2013年推荐患者单次使用备皮消毒剂的原因。临床带头人及其工作人员应确保检查备皮产品的产品标签、查询文献，并联系制造商咨询使用问题。

——BD医学联络员，MS，BSN，RN，CNOR， Lena Pearson

在手术之前，为了提升依从性，要考虑患者必须对皮肤制剂产品有良好耐受和易于实施这两个以患者为中心的因素。这两个因素对于手术前患者洗澡方案以及可能在医疗机构中用消毒产品沐浴皮肤的患者特别重要。

在规划手术时，影响备皮消毒剂选择的关键因素是将要进行手术的部位。不同的身体部位具有不同的皮肤类型、轮廓和内源性菌群，当选择使用的产品和备皮方案实施时，所有这些因素都必须考虑到。这方面在泌尿外科手术中尤为如此，包括腹膜内外手术、阴囊会阴阴道手术、内窥镜检查和经皮肾手术。由于一些消毒剂可能存在使用禁忌症，所以对神经和脊柱手术也构成挑战。手术部位的毛发也对可使用的备皮产品和实施方案有影响。

另一个考虑因素是，该程序是否涉及大量液体，这种情况下将需要使用不会被洗掉的消毒剂。对于日常消毒沐浴，患者可能需要沐浴的各种设施，例如在ICU和疗养院，这些沐浴设施会影响实际使用备皮产品的选择。最后，必须考虑医疗保健提供者对现有备皮产品、产品成本、功效以及易用性的了解。

——高乐氏医疗高级科学家Richard Lowe博士，MPH

当我们考虑皮肤准备时，我们倾向于自然地联想到术前患者备皮。众所周知，手术部位感染是最常见的医院获得性感染（HAI）之一，因此它当然值得我们的关注。

术前洗澡一直是今年所有感染预防和传染病会议的热门话题。由于指南没有提供明确建议，例如频率和产品的选择，所以临床医生就很难知道确切地做什么。在许多情况下，外科医生需要在使用肥皂和水、抗菌肥皂、洗必泰（CHG）肥皂还是洗必泰布的问题上作出判断。我曾经看过一些关于术前沐浴频率的建议，涵盖术前一天晚上到术前三至五天的每个晚上。

另一个常常被忽视的重要因素是患者接受到的使用说明的类型。它们往往很难去跟踪，因为很难确定患者实际上是否执行了正确的皮肤准备程序。但我们有时不得不考虑，总有一些病人没有执行术前淋浴。临床医生和其他医务人员的手卫生也是一个焦点。患者在一个陌生的地方，特别是卧床不起的患者，都有可能导致病人未能坚持其日常个人卫生习惯。这个时候，临床医生应该提醒他们，基本卫生是必要的，并提供卫生用具帮助他们。

——Medline临床服务副总裁，Barb Connell，MS，MT（ASCP）SH

原文：

In this new series for 2017, we offer insights from experts in industry and in healthcare delivery regarding smart evaluation and purchasing of infection prevention and control-related products. In this installation, we address patient skin prep and patient hygiene products.

ICT: What are the clinical situations that pose a challenge to the application of skin prep/patient hygiene?

Clinical situations that pose a challenge for skin preps would depend on assessment of each patient and any preexisting conditions that might affect skin turgor and circulation. Wounds, breaks in the skin, the amount of body hair and areas that are considered “wet sites” (i.e., groin, axilla, between skin folds) would all pose potential challenges for skin antiseptic application. Certain chemicals in skin antiseptics may be irritating to non-intact skin, whereas, large amounts of body hair may increase pooling of the antiseptic liquid and therefore increasing the prep dry time. Lastly, areas of the body that are considered “wet sites” are typically body surfaces that stay moist and warm and contribute to heavy growth of bacterial flora. An additional challenge is the ease of prepping the area of the body (i.e., digits, axilla, between skin folds, etc.). In this situation, the applicator of the product needs to easily fit into the area. If the patient is somewhat immobile or incapacitated, additional staff resources would be needed to properly prep the patient. Clinicians also need to assess for patient allergies in regard to ingredients contained within the skin prep solution. Emotional state as well as mental age of the patient along with language barriers could create challenges regarding the understanding of the prepping procedure and its importance in infection prevention. This is extremely important when the prep will be done at home by the patient (i.e., CHG bathing prior to hospital admission) to ensure proper application by the patient.
-- Fran Canty, clinical science liaison, PDI Healthcare

Selection of a patient prep is based on multiple factors which include: patient allergies and sensitivities, age of the patient, location/type of procedure, anticipated amount of fluid/blood exposure to the surgical site, and surgeon preference. Once these are evaluated, the prep choice also should consider the following: ease of application, ability to immobilize bacteria on the skin, effectiveness of prep after blood and saline challenge, coverage area and cost/value of each surgical prep being considered.
— Kimberly Prinsen, RN, MSN, technical service specialist, 3M Infection Prevention Division 

Patients with high-risk conditions with non-intact skin, such as graft versus host disease or incontinence-associated dermatitis, where patients experience accelerated desquamation of the skin, patients with Stephens Johnson Syndrome or fungal dermatitis associated with severe obesity, present significant challenges in that the products potent enough to manage the bacterial/fungal infections are caustic and cause cytotoxic responses.
— Steve Woody, CEO of Avadim Technologies

Patient, product, procedure and institutional factors all contribute to challenges involving the application of skin prep/patient hygiene products.  A patient’s general hygiene may warrant additional safeguards such as general patient cleansing or hair removal as a necessary measure prior to procedure start. Time pressures associated with turnover metrics and compliance to manufacturer directions for use are difficult, if not impossible ,because of numerous product offerings and variability with instructions. Some of these products not only increase total time to prep the patient but introduce the risk of over-dilution or cross contamination, which led to the FDA recommendation for single-use patient preps in 2013. Clinical leaders and their staff should be sure to examine the product labeling for skin prep products, consult the literature and contact the manufacturer with usage questions.
— Lena Pearson MS, BSN, RN, CNOR, medical science liaison, BD

Prior to surgery, two patient-centric factors to consider are that skin preparation products must be well tolerated by the patient and easy to apply in order to promote compliance. Both factors are particularly important for pre-surgical patient bathing protocols and for patients who might bathe with a skin antiseptic when in a healthcare facility. In planning surgeries, a key factor that influences the choice of skin preparation is the surgical site that is being prepared. Different body sites have different skin types, contours and endogenous flora, all of which must be taken into consideration when selecting the product to use and the protocol for application. This is particularly the case in urology procedures including intraperitoneal and extraperitoneal surgery; scrotal, perineal, and vaginal operations; endoscopy; and percutaneous renal surgery.1 Neurological and spinal procedures also pose challenges as some antiseptics may be contraindicated for use. Hair on the surgical site also influences what can be used and what can be achieved in terms of skin preparation.2 An additional consideration is whether the procedure will involve a lot of fluids which would necessitate using an antiseptic that will resist being washed off under these conditions. For daily antiseptic bathing, the variety of settings in which patients may need to be bathed such as ICUs and nursing homes can influence the choice of products most practical to use. Finally, the healthcare provider’s knowledge of available products, their cost and efficacy and ease of use must be considered.1
 References: 
1. Hemani ML, et al. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol. 2009;11(4):190-5.
 2. Sukul V, et al. Optimal Approaches to Skin Preparation Prior to Neurosurgery. US Neurology. 2010;6(2):14-8. 
— Richard Lowe, PhD, MPH, senior scientist, Clorox Healthcare

When we think of skin prep, we tend to automatically think about prepping the patient’s skin for surgery. Knowing that surgical site infections are one of the most frequent HAIs, this certainly deserves a lot of attention. Pre-op bathing has been a hot topic at all the Infection prevention and Infectious disease conferences this year. Since the guidelines do not provide definitive recommendations, such as how often and with what product, it becomes difficult for clinicians to know exactly what to do. In many cases, the surgeon decides whether to use soap and water, antibacterial soap, CHG soap or CHG cloths. I have also seen the frequency of bathing range from the night before and morning of surgery, up to every evening for three or five days before surgery. Another important factor that is often forgotten is the type of instructions patients receive. They’re often difficult to follow and it’s hard to determine that the patient actually performed the correct skin prep procedure. We don’t always think about it, but there are some patients that do not have a shower. Hand hygiene for clinicians and staff is also a focal point. Being in a strange place and sometimes being bed-bound can lead to patients abandoning their regular personal hygiene routine. It is up to the clinicians to remind them that basic hygiene is necessary and provide the tools to help them accomplish it.  
— Barb Connell, MS, MT(ASCP)SH, vice president of clinical services, Medline

图文编辑：独白

审稿：赵静 孙庆芬