Perioperative Skin Preparation Liaison: Anthony T Tokarski BS Leaders: David Blaha MD (US), Michael A. Mont MD (US), Parag Sancheti MS, DNB, MCh (Inter- national) Delegates: Lyssette Cardona MD, MPH, MHA, AAHIVS, FIDSA, Gilberto Lara Cotacio MD, Mark Froimson MD, Bhaveen Kapadia MD, James Kuderna MD, PhD, Juan Carlos Lo ´ pez MD, Wadih Y Matar MD, MSc, FRCSC, Joseph McCarthy MD, Rhidian Morgan-Jones MB BCh, FRCS, Michael Patzakis MD, Ran Schwarzkopf MD, Gholam Hossain Shahcheraghi MD, Xifu Shang MD, Petri Virolainen MD, PhD, Montri D. Wongworawat MD, Adolph Yates Jr, MD Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/jor.22548 ß 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:S26–S30, 2014. Question 1A: Is there a role for preoperative skin cleansing with an antiseptic? Consensus Yes. Preoperative cleansing of the skin with chlorhexi- dine gluconate (CHG) should be implemented. In the presence of a sensitivity to CHG, or when it is unavailable, it is our consensus that antiseptic soap is appropriate. Delegate Vote Agree: 90%, Disagree: 8%, Abstain: 2% (Strong Con- sensus) Question 1B: What type and when should preoperative skin cleansing with an antiseptic be implemented? Consensus We recommend that whole-body skin cleansing should start at least the night prior to elective arthroplasty. It is a consensus that after bathing patients are advised to sleep in clean garments and bedding without the application of any topical products. Delegate Vote Agree: 85%, Disagree: 10%, Abstain: 5% (Strong Consensus) Justification Preoperative showering or cleansing Two meta-analyses of seven randomized control trials (RCT) performed by the Cochrane group found that preoperative showering with CHG did not reduce the rate of surgical site infection (SSI) when compared to no shower (three RCTs) or placebo (four RCTs). 1 Two observational studies using CHG wipes in total joint arthroplasty patients demonstrated a non-statistically significant reduction in the incidence of SSI. 2,3 John- son et al. 2 found in a prospective consecutive series that patients who used CHG wipes 1 day preoperative- ly and the morning of the operation had a lower incidence of SSI than patients who did not comply with this protocol prior to total hip arthroplasty. These results were reproduced using a similar protocol in total knee arthroplasty patients. 3 In neither study were patients randomized to receive treatment or no treatment; however, the authors compared patients who completely complied with the protocol to patients who did not comply. Patients with partial compliance were excluded from both studies. Chlorhexidine and methicillin-resistant organisms A systematic review of the literature conducted by Karki and Cheng reported on a meta-analysis of two before-and-after studies that showed non-rinse skin cleansing with CHG washcloths was effective in reducing the risk of methicillin-resistant Staphylococ- cus aureus (MRSA) skin colonization in the setting of the intensive care unit. However, a meta-analysis of four before-and-after studies showed no evidence that CHG washcloths reduce the risk of MRSA infection. 4 Other studies have shown that CHG cleansing leads to a lower rate of MRSA colonization in the hospital setting. 5,6 One case-control study evaluating a protocol of a 5-day course of intranasal mupirocin and daily CHG cloths (beginning 1 day before surgery and continuing the day of surgery and postoperative Days 1–3) in a non-general surgery population reported statistically significant decreases in the rate of MRSA SSI in the two years following implementation of this protocol. 7 However, in these studies CHG washcloths were used as part of a broader Staphlylococcus aureus decolonization proto- col. Therefore, it is not possible to determine the impact on SSI of decolonization or CHG wash clothes, independently. Timing of preoperative shower or cleansing No studies have focused on the impact of the time or duration of preoperative cleansing with an antiseptic agent. Some studies have implemented protocols of washing the surgical site once on the night prior to surgery and on the morning of the operation, 3,8,9 while other protocols have continued washing through post- operative Day 3. 7 One study conducted with a small sample size of volunteers noted decreased microbial colonization with a CHG wash over the course of a 5-day period. 10 Currently, the Centers for Disease S26 JOURNAL OF ORTHOPAEDIC RESEARCH JANUARY 2014