An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts

Alcohol-Based Chlorhexidine and Potassium Sorbate Rub Strengthens the Effectiveness of Traditional Hand Scrubbing and Improves Long-Lasting Effectiveness-Evaluation of Hand Preparation Protocols According to EN 12791

Despite the advantages of surgical handrub in terms of the ease of application and effectiveness, chlorhexidine (CHG)-based hand scrubbing remains the preferred method for surgical hand preparation. However, it does not systematically meet the non-inferiority requirement of the European norm (EN) 12791 with respect to n-propanol (the reference product) and does not provide the sustained efficacy expected for these long-lasting agents. Commercially available alcohol-based products have also failed to demonstrate sustained efficacy according to EN 12791. Multi-step protocols enhance the efficacy of hand scrubbing, yet their extended disinfection duration might diminish their allure for healthcare professionals. In this study, we show that hand scrubbing with CHG 4% followed by a 1 min rubbing with the novel formulation of ethanol (Et) 70%/CHG 3% plus 0.3% potassium sorbate food additive (PS) meets the non-inferiority requirement and demonstrates sustained efficacy when tested according to EN 12791. The immediate and 3 h effect of this protocol was significantly higher than that of n-propanol and the homologous disinfection protocol without PS (CHG 4% hand scrub plus Et 70%/CHG 3% rub), demonstrating that the inclusion of PS confers a notable residual effect. We speculate that this non-volatile ingredient acts synergistically with CHG. This promising combination represents an alternative method for the development of new disinfection strategies.

Bacterial Decontamination: Bowel Preparation and Chlorhexidine Bathing

Infectious complications following bowel surgery continues to be a leading cause of postoperative morbidity. Both patient- and procedure-related factors contribute to risk. Compliance with evidence-based process measures is the best strategy for prevention of surgical site infections. Three process measures that aim to reduce the bacterial load present at the time of surgery are mechanical bowel preparation, oral antibiotics, and chlorhexidine bathing. There is heightened awareness of surgical site infections, in part due to improved access to reliable postoperative complication data for colon surgery as well as incorporation of surgical site infection into public reporting and pay-for-performance payment models. As a result, the literature has improved with regard to the effectiveness of these methods in reducing infectious complications. Herein, we provide the evidence to support adoption of these practices into colorectal surgery infection prevention programs.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Impact of methods and duration of surgical hand scrub on bacterial count: A randomized controlled trial

BACKGROUND

There is no standard protocol for surgical scrubbing. This study aims to compare the effectiveness of surgical hand scrub duration and method by analyzing their effects on bacterial count.

METHODS

The study was conducted on 180 surgical nurses and surgeons. While the duration of surgical hand scrub in Groups I and II was one minute, participants in Group I used a nail brush, whereas Group II did not. Similarly, the duration of surgical hand scrub in Groups III and IV was two minutes, but Group III used a nail brush, whereas Group IV did not. Bacterial count on the hands of all participants was measured before and after the surgical hand scrub and after the surgery by using the glove juice method.

RESULTS

Bacterial count on the hands of the participants in Group III after surgical hand scrub was significantly higher than Group IV (P < .001). We did not find any statistically significant difference between Group II and Group IV in terms of bacterial count on the hands immediately after surgical hand scrub and after the surgery (P = .401, P =.658, respectively).

CONCLUSIONS

This study found that brushing during surgical hand scrub increased the number of bacteria on the hand. Besides, one-minute surgical hand scrub was equally effective as two-minute scrub to reduce the number of bacteria on the hand.

The impact of gel fingernail polish application on the reduction of bacterial viability following a surgical hand scrub

OBJECTIVE

To determine the effect of gel nail polish application on the reduction of bacterial viability immediately after a surgical hand scrub.

STUDY DESIGN

Randomized controlled trial.

SAMPLE POPULATION

Ten fingernails each from 40 female health care professionals and students.

METHODS

Participants' fingernails were randomized to receive no polish or gel nail polish during a manicure from a licensed manicurist. One day and 14 days after manicure, participants' fingernails were sampled before and after a surgical hand scrub with chlorhexidine gluconate. The samples for each fingernail were serially diluted, plated on a Trypsin sheep blood agar and MacConkey's agar plate, and incubated for 36 h. For each plate, bacterial colony forming units (CFU)/ml were determined. Mixed linear models were used to assess factors associated with the logarithmic reduction of viable bacterial counts from pre- to post-surgical scrub.

RESULTS

In the final model, no association was detected between gel nail polish and reduction of viable bacterial count (p = .09). On Day 14, among longer nail lengths (2 to <3-mm and ≥3-mm), surgical scrubs resulted in greater reduction in bacterial counts in left-handed than right-handed participants (p < .01). Increasing nail length was correlated with increased CFU/ml post-scrubbing (p < .001).

CONCLUSION

Application of gel nail polish did not seem to affect the ability of surgical scrub to reduce bacterial viability 1 and 14 days after a manicure.

CLINICAL IMPACT

This study does not provide evidence to prevent application of gel nail polish on short fingernails in surgeons prior to surgical hand scrub with chlorhexidine gluconate.

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery

OBJECTIVE

To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.

DESIGN

Uncontrolled before-and-after study.

SETTING

Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.

PATIENTS

Patients undergoing surgery between January 2016 and April 2018.

INTERVENTION

A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.

RESULTS

Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%-65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31-5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.

CONCLUSIONS

This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.

Operating Room Hand Preparation: To Scrub or to Rub?

BACKGROUND

The alcohol rub has been proposed as an alternative to the traditional surgical scrub in preparing the hands for surgical procedures. Few reviews have examined critically the evidence that favors or discredits the use of the alcohol rub instead of the traditional scrub.

METHODS

A review of available published literature was undertaken to define the evidence for the best methods for hand preparation before surgical procedures. The focus of this literature review was to compare the bacteriologic and clinical outcomes of conventional surgical scrubbing of the hands compared with alcohol rubs.

RESULTS

The bacteriologic studies of the hands after the conventional scrub versus the alcohol rub demonstrated consistently comparable or superior reductions in bacterial presence on the hand with the alcohol rub. Only four clinical studies were identified that compared the scrub versus the rub in the frequency of surgical site infections. No difference in surgical site infections were identified.

CONCLUSIONS

The alcohol rub appears to have comparable results to the surgical scrub and is a reasonable alternative in preparation of the hands for surgical procedures.

Antiseptic efficacies of waterless hand rub, chlorhexidine scrub, and povidone-iodine scrub in surgical settings: a meta-analysis of randomized controlled trials

BACKGROUND

Presurgical hand washing is crucial for preventing surgical site infections (SSIs). Chlorhexidine gluconate (CHG) and povidone-iodine (PI) products have been conventionally used as hand scrubs for presurgical hand preparation. However, waterless hand rub (WHR) products have been developed for operating room staff.

AIM

The aim of this study was to conduct a systematic review and meta-analysis to compare the antiseptic efficacies of WHR, CHG, and PI in surgical settings.

METHODS

PubMed, Embase, and Cochrane Library databases as well as the ClinicalTrials.gov registry were searched for studies published before October 2018. Randomized controlled trials (RCTs) comparing the clinical outcomes of the use of WHRs, CHG, or PI for presurgical hand washing were included. A random effects model was used for meta-analysis. Colony-forming unit (cfu) counts, SSI rates, and preference and compliance were determined to measure efficacies.

FINDINGS

Eleven RCTs involving 5135 participants were included. Residual cfu counts were significantly lower in the WHR and CHG groups than in the PI group. The differences in cfu counts between the WHR and CHG groups were non-significant. No significant differences were observed in the SSI rates between the WHR and traditional hand scrub groups. Moreover, WHRs were considered most favourable and were associated with higher compliance rates than the other products.

CONCLUSION

WHRs and CHG exhibited higher antiseptic efficacies than PI. However, additional studies with consistent outcome measurements and accurate grouping are required to obtain comprehensive results. Moreover, preference, compliance, and the cost determine the selection of hand wash products.

Evaluation of fast-acting bactericidal activity and substantivity of an antiseptic agent, olanexidine gluconate, using an ex vivo skin model

PURPOSE

We assessed the fast-acting bactericidal activity and substantivity of olanexidine gluconate (OLG) to investigate its remaining bactericidal activity on the skin after rinsing and drying by using an ex vivo Yucatan micropig (YMP) skin model.

METHODOLOGY

The fast-acting bactericidal activity was evaluated in pigskin models inoculated with methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, vancomycin-resistant Enterococcus faecalis (VRE), Acinetobacter baumannii, Corynebacterium minutissimum and Cutibacterium acnes. To evaluate substantivity, the YMP skin piece first had 1.5 % OLG, chlorhexidine gluconate (CHG) formulations or 10 % povidone-iodine (PVP-I) applied to it, and was then rinsed with distilled water, incubated for 4, 6, 8 or 12 h and inoculated with the test bacteria (MRSA, S. epidermidis and VRE). The viable bacteria remaining at 1 min of exposure of bacteria were counted to measure the quantity of antiseptic molecules retaining bactericidal activity. To determine the factors contributing to the substantivity, the stratum corneum (SC) of the YMP skin that had had OLG or CHG applied to it was exfoliated using a tape-stripping method and the amount of antiseptic was quantitated.

RESULTS

OLG showed a fast-acting bactericidal activity that was similar to or stronger than that of CHG formulations up to a concentration of 1 % and PVP-I with a short exposure time of 30 s, and substantivity until 12 h after rinsing, whereas the other antiseptics hardly showed any substantivity. There was 2.8 times or more OLG in the SC than CHG.

CONCLUSION

OLG has fast-acting activity and substantivity, which are required properties for an antiseptic, and is useful for preventing infections.

Comparison of chlorhexidine–isopropanol with isopropanol skin antisepsis for prevention of surgical-site infection after abdominal surgery

Background

Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial.

Methods

Between August and October 2014, patients undergoing abdominal surgery received preoperative skin antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174).

Results

In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034).

Conclusion

This study showed a benefit of adding chlorhexidine to alcohol for skin antisepsis in reducing early SSI compared with alcohol alone.

Waterless Hand Rub Versus Traditional Hand Scrub Methods for Preventing the Surgical Site Infection in Orthopedic Surgery

MINI: Fourteen hundred consecutive patients were investigated for evaluating the utility of waterless hand rub before orthopaedic surgery. The risk in the surgical site infection incidence was the same, but costs of liquids used for hand hygiene were cheaper and the hand hygiene time was shorter for waterless protocol, compared with traditional hand scrub.

STUDY DESIGN

A retrospective cohort study with prospectively collected data.

OBJECTIVE

The aim of this study was to compare SSI incidences, the cost of hand hygiene agents, and hand hygiene time between the traditional hand scrub and the waterless hand rub protocols before orthopedic surgery.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSI) prolong hospitalization and are a leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand rub protocol comprising alcohol based chlorhexidine gluconate for use before surgery was developed, but no studies have yet examined its utility in orthopedic surgery.

METHODS

Fourteen hundred consecutive patients who underwent orthopedic surgery (spine, joint replacement, hand, and trauma surgeries) in our hospital since April 1, 2012 were included. A total of 712 cases underwent following traditional hand scrub between April 1, 2012 and April 30, 2013 and 688 cases underwent following waterless hand rub between June 1, 2013 and April 30, 2014. We compared SSI incidences within all and each subcategory between two hand hygiene protocols. All patients were screened for SSI within 1 year after surgery. We compared the cost of hand hygiene agents and hand hygiene time between two groups.

RESULTS

The SSI incidences were 1.3% (9 of 712) following the traditional protocol (2 deep and 7 superficial infections) and 1.1% (8 of 688) following the waterless protocol (all superficial infections). There were no significant differences between the two groups. The costs of liquids used for one hand hygiene were about $2 for traditional hand scrub and less than $1 for waterless hand rub. The mean hand hygiene time was 264 seconds with the traditional protocol and 160 seconds with the waterless protocol.

CONCLUSION

Waterless hand rub with an alcohol based chlorhexidine gluconate solution can be a safe, quick, and cost-effective alternative to traditional hand scrub.

LEVEL OF EVIDENCE

3.

Surgical hand preparation with chlorhexidine soap or povidone iodine: new methods to increase immediate and residual effectiveness, and provide a safe alternative to alcohol solutions

BACKGROUND

Surgical use of 4% chlorhexidine soap (CHX-4) and 10% povidone iodine (PVP-I-10) does not meet the standards defined by EN 12791.

AIM

To investigate the possibility of increasing the immediate and residual effects of these antiseptics.

METHODS

Over three consecutive weeks, n-propanol, standard CHX-4 and PVP-I-10 were tested in two experimental groups of volunteers. The new method for applying the antiseptic substances involved standard hand rub and rinse of CHX-4 or PVP-I-10, followed by application of an aqueous solution based on 5% chlorhexidine or PVP-I-10 with no further rinsing of the hands prior to donning gloves. Samples were taken to assess immediate and residual effects, analysing the logarithmic reduction of colony-forming units.

FINDINGS

At t=0 h, n-propanol was superior in bactericidal effect to standard CHX-4 (P<0.05), but the new chlorhexidine protocol was superior to both standard CHX-4 (P<0.01) and n-propanol (P<0.05); the same effect was observed at t=3 h (residual effect). At t=0 h, n-propanol was significantly superior to standard PVP-I-10, but the new PVP-I-10 protocol was superior, although not significantly, to n-propanol. There was no significant residual effect at t=3 h.

CONCLUSION

The new protocol for chlorhexidine application permits surgical hand preparation with chlorhexidine, as a safe alternative to alcohol solutions, because it meets the standards defined by EN 12791.

Preoperative Hand Decontamination in Ophthalmic Surgery: A Comparison of the Removal of Bacteria from Surgeons' Hands by Routine Antimicrobial Scrub versus an Alcoholic Hand Rub

PURPOSE

The goal of this experiment was to evaluate and compare the antimicrobial efficacy of routine preoperative hand washing using commercial medicated sponge brushes versus an alcoholic hand rub, by comparing bacterial growth on ophthalmic surgeons' hands after application of each of these methods.

METHODS

Twenty ophthalmic surgeons were recruited at the Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Samples were collected twice from the hands of each surgeon after hand decontamination using two different protocols during routine surgical practice. The routine preparation consisted of a 3-minute surgical scrub using commercial brush-sponges incorporating either 4% chlorhexidine gluconate (CHG) or 1% povidone-iodine (PVP-I) formulations with detergent, followed by drying the hands with a sterile towel, while the 70% ethanol solution was applied for 60-seconds and allowed to air dry. Half of the group was randomly assigned to provide samples first after the routine method and the alcoholic solution a week later, and the other half of the group was sampled in the reverse order. Viable counts of bacteria were evaluated using a modified glove juice method. Bacterial colonies were enumerated after incubation for 24 hours and expressed as colony forming units (CFU)/mL for each pair of hands.

RESULTS

Geometric mean counts were 1310 and 39 CFU/mL, in the routine and alcohol rub groups, respectively, representing a mean log₁₀ reduction in 1.53. The difference between the paired bacterial counts for the routine versus the alcohol rub was statistically significant (p < 0.0001). There was no statistically significant difference between log₁₀ reductions for CHG and PVP-I (p = 0.97).

CONCLUSIONS

This study provides evidence that an alcohol rub protocol is more effective in reducing bacterial counts on hands than routine surgical hand preparation with PVP-I and CHG in a population of practicing ophthalmic surgeons in the operative clinical setting. Thus, it provides a safe alternative as a preoperative hand disinfection method.

The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management

INTRODUCTION

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique.

METHODS

The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations.

RESULTS

The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices.

CONCLUSION

Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Antiseptic Effect of Conventional Povidone–Iodine Scrub, Chlorhexidine Scrub, and Waterless Hand Rub in a Surgical Room: A Randomized Controlled Trial

OBJECTIVE

Effective perioperative hand antisepsis is crucial for the safety of patients and medical staff in surgical rooms. The antimicrobial effectiveness of different antiseptic methods, including conventional hand scrubs and waterless hand rubs, has not been well evaluated.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial was conducted to investigate the effectiveness of the 3 antiseptic methods among surgical staff of Taipei Medical University—Shuang Ho Hospital. For each method used, a group of 80 participants was enrolled.

INTERVENTION

Surgical hand cleansing with conventional 10% povidone–iodine scrub, conventional 4% chlorhexidine scrub, or waterless hand rub (1% chlorhexidine gluconate and 61% ethyl alcohol).

RESULTS

Colony-forming unit (CFU) counts were collected using the hand imprinting method before and after disinfection and after surgery. After surgical hand disinfection, the mean CFU counts of the conventional chlorhexidine (0.5±0.2, P<0.01) and waterless hand rub groups (1.4±0.7, P<0.05) were significantly lower than that of the conventional povidone group (4.3±1.3). No significant difference was observed in the mean CFU count among the groups after surgery. Similar results were obtained when preexisting differences before disinfection were considered in the analysis of covariance. Furthermore, multivariate regression indicated that the antiseptic method (P=.0036), but not other variables, predicted the mean CFU count.

CONCLUSIONS

Conventional chlorhexidine scrub and waterless hand rub were superior to a conventional povidone–iodine product in bacterial inhibition. We recommend using conventional chlorhexidine scrub as a standard method for perioperative hand antisepsis. Waterless hand rub may be used if the higher cost is affordable.

Infect Control Hosp Epidemiol 2017;38:417–422

Reproducibility and Workability of the European Test Standard EN 12791 Regarding the Effectiveness of Surgical Hand Antiseptics A Randomized, Multicenter Trial

Objectives.

To evaluate the reproducibility and workability of the in vivo test model of the European test standard EN 12791 regarding the effectiveness of surgical hand antiseptics and, as a secondary objective, to evaluate the power of the model to discriminate between the effectiveness of various formulations of surgical hand antiseptics.

Design.

Prospective, randomized, multicenter study with a Latin square design.

Setting.

Five laboratories at 2 universities, 2 disinfectant manufacturers, and 1 private testing institution.

Participants.

Twenty healthy adults in each laboratory.

Intervention.

Surgical hand antisepsis was performed by scrubbing with chlorhexidine gluconate 4% detergent (CHG) or by rubbing the hands with propan-2-OL (70% by volume; Iso 70) or ethanol 85% (E 85); rubbing the hands and forearms for 3 minutes with propan-1-OL (N 60) was used as the reference disinfection procedure. We deliberately chose to use these antiseptics at the given concentrations because they were intended to cover the range of typical antiseptics submitted for approval according to EN 12791.

Methods.

In once-weekly tests, the immediate effects of the 4 antiseptics were established according to the method laid down in EN 12791 by assessing the release of skin flora from the fingertips as viable bacteria counts per milliliter of sampling fluids before treatment and viable bacteria counts immediately after treatment, separately for both hands, such that after 4 weeks each volunteer had used every formulation once.

Results.

The mean log reduction factor (RF) for the release of bacterial skin flora (the log RF was calculated as the log count before treatment minus the log count after treatment) and corresponding standard deviations for the 4 hand antisepsis formulations were as follows: for CHG, 1.1 ± 0.3 colony-forming units (cfu) per milliliter of sampled fluid; for Iso 70, 1.7 ± 0.3 cfu/mL; for E 85, 2.1 ± 0.3 cfu/mL; and for N 60, 2.4 ± 0.4 cfu/mL. The differences between these values proved significant (P<.001) by analysis of variance and in Tukey's “honestly significantly different” (HSD) post hoc test. Although, with regard to their immediate antibacterial activity, the same ranking of these antiseptics was found at all laboratories, the levels of efficacy were significantly different across laboratories (P<.001); no statistical difference was found between left and right hands (P>.01). Relating the log RF values of the other 3 formulations to those of the reference formulation (N 60) abolished differences between laboratories (P = .16); in addition, the interclass correlation coefficient decreased from 9.1% to 4.5%. With 20 volunteers, a minimum difference of 0.47 log between the mean log RFs of the reference formulation and an inferior test formulation will be detected as significant at an α of .05 (1-sided) and a 1 — β value of .8.

Conclusion.

The test method described in EN 12791 yielded the same conclusion on the effectiveness of the tested formulations in every laboratory and proved, therefore, reproducible and workable.

The Effects of Surgical Hand Scrubbing Protocols on Skin Integrity and Surgical Site Infection Rates: A Systematic Review

This systematic review aimed to critically appraise and synthesize updated evidence regarding the effect of surgical-scrub techniques on skin integrity and the incidence of surgical site infections. Databases searched include the Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Embase, and Cochrane Central. Our review was limited to eight peer-reviewed, randomized controlled trials and two nonrandomized controlled trials published in English from 1990 to 2015. Comparison models included traditional hand scrubbing with chlorhexidine gluconate or povidone-iodine against alcohol-based hand rubbing, scrubbing with a brush versus without a brush, and detergent-based antiseptics alone versus antiseptics incorporating alcohol solutions. Evidence showed that hand rubbing techniques are as effective as traditional scrubbing and seem to be better tolerated. Hand rubbing appears to cause less skin damage than traditional scrub protocols, and scrub personnel tolerated brushless techniques better than scrubbing using a brush.

Surgical hand antisepsis to reduce surgical site infection

BACKGROUND

Medical professionals routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient micro-organisms and inhibit the growth of resident micro-organisms. Antisepsis may reduce the risk of surgical site infections (SSIs) in patients.

OBJECTIVES

To assess the effects of surgical hand antisepsis on preventing surgical site infections (SSIs) in patients treated in any setting. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH METHODS

In June 2015 for this update, we searched: The Cochrane Wounds Group Specialized Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations) and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion and trial quality and extracted data.

MAIN RESULTS

Fourteen trials were included in the updated review. Four trials reported the primary outcome, rates of SSIs, while 10 trials reported number of CFUs but not SSI rates. In general studies were small, and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. SSIsOne study randomised 3317 participants to basic hand hygiene (soap and water) versus an alcohol rub plus additional hydrogen peroxide. There was no clear evidence of a difference in the risk of SSI (risk ratio (RR) 0.97, 95% CI 0.77 to 1.23, moderate quality evidence downgraded for imprecision).One study (500 participants) compared alcohol-only rub versus an aqueous scrub and found no clear evidence of a difference in the risk of SSI (RR 0.56, 95% CI 0.23 to 1.34, very low quality evidence downgraded for imprecision and risk of bias).One study (4387 participants) compared alcohol rubs with additional active ingredients versus aqueous scrubs and found no clear evidence of a difference in SSI (RR 1.02, 95% CI 0.70 to 1.48, low quality evidence downgraded for imprecision and risk of bias).One study (100 participants) compared an alcohol rub with an additional ingredient versus an aqueous scrub with a brush and found no evidence of a difference in SSI (RR 0.50, 95% CI 0.05 to 5.34, low quality evidence downgraded for imprecision). CFUsThe review presents results for a number of comparisons; key findings include the following.Four studies compared different aqueous scrubs in reducing CFUs on hands.Three studies found chlorhexidine gluconate scrubs resulted in fewer CFUs than povidone iodine scrubs immediately after scrubbing, 2 hours after the initial scrub and 2 hours after subsequent scrubbing. All evidence was low or very low quality, with downgrading typically for imprecision and indirectness of outcome. One trial comparing a chlorhexidine gluconate scrub versus a povidone iodine plus triclosan scrub found no clear evidence of a difference-this was very low quality evidence (downgraded for risk of bias, imprecision and indirectness of outcome).Four studies compared aqueous scrubs versus alcohol rubs containing additional active ingredients and reported CFUs. In three comparisons there was evidence of fewer CFUs after using alcohol rubs with additional active ingredients (moderate or very low quality evidence downgraded for imprecision and indirectness of outcome). Evidence from one study suggested that an aqueous scrub was more effective in reducing CFUs than an alcohol rub containing additional ingredients, but this was very low quality evidence downgraded for imprecision and indirectness of outcome.Evidence for the effectiveness of different scrub durations varied. Four studies compared the effect of different durations of scrubs and rubs on the number of CFUs on hands. There was evidence that a 3 minute scrub reduced the number of CFUs compared with a 2 minute scrub (very low quality evidence downgraded for imprecision and indirectness of outcome). Data on other comparisons were not consistent, and interpretation was difficult. All further evidence was low or very low quality (typically downgraded for imprecision and indirectness).One study compared the effectiveness of using nail brushes and nail picks under running water prior to a chlorhexidine scrub on the number of CFUs on hands. It was unclear whether there was a difference in the effectiveness of these different techniques in terms of the number of CFUs remaining on hands (very low quality evidence downgraded due to imprecision and indirectness).

AUTHORS' CONCLUSIONS

There is no firm evidence that one type of hand antisepsis is better than another in reducing SSIs. Chlorhexidine gluconate scrubs may reduce the number of CFUs on hands compared with povidone iodine scrubs; however, the clinical relevance of this surrogate outcome is unclear. Alcohol rubs with additional antiseptic ingredients may reduce CFUs compared with aqueous scrubs. With regard to duration of hand antisepsis, a 3 minute initial scrub reduced CFUs on the hand compared with a 2 minute scrub, but this was very low quality evidence, and findings about a longer initial scrub and subsequent scrub durations are not consistent. It is unclear whether nail picks and brushes have a differential impact on the number of CFUs remaining on the hand. Generally, almost all evidence available to inform decisions about hand antisepsis approaches that were explored here were informed by low or very low quality evidence.

Usage of ultraviolet test method for monitoring the efficacy of surgical hand rub technique among medical students

BACKGROUND

Adequate hand movements are essential in surgical hand rub, so it is important for medical students to learn it correctly. To assess its efficacy, we aimed to use ultraviolet (UV) light test after applying fluorescent solution.

METHODS

Digital images of the hands of 253 medical students were analyzed during "Basic Surgical Techniques" course on the 10th (Survey 1) and 14th (Survey 2) week of the curriculum to check the process and the skills development. The last step of the surgical hand rub was performed with a fluorescent solution, and then the hands were placed under UV light. Photographs were taken and analyzed. Every uncovered area was considered an error. Number and the localization of missed spots and its extent was determined. For evaluation, palmar (P) and dorsal (D) sides of the hands were divided into regions of interest (1-distal phalanxes, 2-thumb and first metacarpus, 3-second to fifth fingers, and 4-second to fifth metacarpals).

RESULTS

Various magnitude and number of failure occurred in 123 (48.61%) students in survey 1 and in 65 (25.69%) in survey 2. The most frequent sites of the missed spots were D/2 and P/4 region in survey 1 and D/1 and P/4 in survey 2. There was an improvement seen in survey 2, as shown by a decrease in the number and extent of missed spots. Right-handed students made fewer mistakes on their nondominant hands than left-handed students (n = 23) did.

DISCUSSION

The method was suitable to monitor the efficacy of surgical hand rub technique and identify the mistakes and the critical sites. The main advantage of the UV test was the immediate feedback, which resulted in a distinct improvement.

CONCLUSION

Applying the UV test to the medical education and training may contribute to improvement in the compliance and the efficacy of the technique of surgical hand rub among the students.

Influence of Rings on the Efficacy of Hand Sanitization and Residual Bacterial Contamination

Background.

Previous studies, conducted before widespread use of scrubless, alcohol-based hand sanitizers, demonstrated increased residual bacterial counts after hand hygiene on hands with jewelry.

Objective.

To compare the impact of finger rings on the effectiveness of scrubless and water-aided alcohol-based hand sanitization methods with that of povidone-iodine scrub.

Design.

Randomized, controlled study.

Setting.

University hospital.

Participants.

Sixty volunteer subjects from a pool of perioperative staff and medical students.

Intervention.

After recruitment, participants wore a ring on one hand and no ring on the other hand. They were randomly assigned to perform hand hygiene with a povidone-iodine scrub, an alcohol wash, or a waterless alcohol-chlorhexidine lotion (n = 20 subjects per method). After subjects completed hand hygiene, gloves were placed on their hands by means of sterile methods, and a “glove juice” technique was used to obtain samples for culture. The number of colony-forming units in each culture was counted, and the data were compared.

Results.

There was no significant difference in the number of bacteria between hands with and hands without rings for the groups that used alcohol wash or alcohol-chlorhexidine lotion. However, for the povidone-iodine group, the number of bacteria on hands with rings was greater than the number on hands without rings (P < .05). The hands of participants who used waterless alcohol-chlorhexidine had the lowest bacterial count, regardless of the presence of rings (P < .01).

Conclusions.

The presence of rings does not negatively impact the effectiveness of alcohol-based hand sanitizers. Use of waterless alcohol-chlorhexidine lotion resulted in the lowest bacterial count.

Prevention of surgical site infections

In the current era of pay-for-performance standards, the incidence of surgical site infections is increasingly becoming an institutional marker of quality assurance. Surgical site infections lead to increased morbidity and mortality in the surgical population and contribute to an already rising healthcare cost. As a result, the surgical community goes to great lengths to prevent this costly and occasionally lethal complication. Many practices are evidence based, however, many are not. In this article, the most commonly used preventive strategies in practice today and the evidence behind each are reviewed. In addition, an overview of the epidemiology, pathophysiology and microbiology of surgical site infections will be provided.

Comparison of surgical hand scrub and alcohol surgical hand rub on reducing hand microbial burden

This study was performed to compare the effects of two hand decontamination methods on the microbial burden of operating room staff hands. The surgical hand washing methods compared were a traditional surgical hand scrub using a povidone iodine solution, and a social wash using a liquid non-antibacterial soap followed by the application of an alcoholic hand rub.

Effect of surgical site infections with waterless and traditional hand scrubbing protocols on bacterial growth

BACKGROUND

Alcohol-based antiseptic scrub formulation has long been used for hand cleansing in the operating room. Recently, a waterless surgical scrub formulation containing 1% chlorhexidine gluconate was developed to provide a comparable antiseptic effect. The present study explored the scrub time required when using waterless hand scrub and traditional hand scrub formulations for operating room staff and compared bacterial growth on the hands after surgical hand scrubbing in the 2 groups.

METHODS

Operating room staff members (n = 100) were recruited randomly from medical centers in Taiwan. Two days in July 2010 were chosen for testing in advance, and the participants were assigned equally to use either a waterless scrub or traditional scrub formulation on 2 separate days. Scrub times were recorded and microorganisms on hands after scrubbing were sampled on 2 separate days. Two days after sampling, the colonies grown on bacterial culture plates were counted and expressed as colony-forming units (CFU) per plate.

RESULTS

At 48 hours after sampling, microorganisms were found on 7 of the 50 plates in the waterless scrub group (1-9 CFU) and on 7 of the 50 plates in the traditional scrub group (1-5 CFU). The difference between the groups was no statistically significant (95% CI, 0.85-1.71). Nine surgical patients were found to have contact with the 14 participants with microorganisms found after scrubbing in the operating room. Among these 9 patients, 1 patient with diabetes who underwent amputation developed local reddish swelling suggestive of surgical site infection necessitating a 7-day course of cefalexin. The incidence of surgical site infection was not signifcantly different in the 2 groups.

CONCLUSIONS

Our findings suggest that waterless hand scrub is as effective as traditional hand scrub in cleansing the hands of microorganisms and more efficient in terms of scrub time.

Presurgical hand antisepsis: concepts and current habits of veterinary surgeons

OBJECTIVE

To assess current habits for surgical hand preparation among veterinary surgical specialists and to compare data with current guidelines for hand asepsis techniques.

STUDY DESIGN

Survey of veterinary surgical specialists.

SAMPLE POPULATION

Diplomates of the American (ACVS) and European Colleges of Veterinary Surgeons (ECVS).

METHODS

An internet-based survey of hand preparation methods before surgical procedures was conducted of 1300 listed ACVS and ECVS Diplomates.

RESULTS

A 42.6% response rate was obtained. Approximately, 80% of respondents use disinfecting soaps as a primary method for hand antisepsis. Of those, 81% use chlorhexidine-based scrubs and 7% use a neutral soap followed by a hydroalcoholic solution.

CONCLUSIONS

Contrary to current recommendations of the World Health Organization and scientific evidence supporting use of hydro-alcoholic rubs for presurgical hand preparation, veterinary surgical specialists still use surgical scrub solutions containing disinfecting soaps.

A meta-analysis of the published literature on the effectiveness of antimicrobial soaps

The goal of this research was to conduct a systematic quantitative analysis of the existing data in the literature in order to determine if there is a difference between antimicrobial and nonantimicrobial soaps and to identify the methodological factors that might affect this difference. Data on hand washing efficacy and experimental conditions (sample size, wash duration, soap quantity, challenge organism, inoculum size, and neutralization method) from published studies were compiled and transferred to a relational database. A total of 25 publications, containing 374 observations, met the study selection criteria. The majority of the studies included fewer than 15 observations with each treatment and included a direct comparison between nonantimicrobial soap and antimicrobial soap. Although differences in efficacy between antimicrobial and nonantimicrobial soap were small (∼0.5-log CFU reduction difference), antimicrobial soap produced consistently statistically significantly greater reductions. This difference was true for any of the antimicrobial compounds investigated where n was >20 (chlorhexidine gluconate, iodophor, triclosan, or povidone). Average log reductions were statistically significantly greater (∼2 log CFU) when either gram-positive or gram-negative transient organisms were deliberately added to hands compared with experiments done with resident hand flora (∼0.5 log CFU). Our findings support the importance of using a high initial inoculum on the hands, well above the detection limit. The inherent variability in hand washing seen in the published literature underscores the importance of using a sufficiently large sample size to detect differences when they occur.

Influence of methylation on the antibacterial properties of triclosan in Pasteurella multocida and Pseudomonas aeruginosa variant strains

The opportunistic bacterium Pasteurella multocida is extremely susceptible to the hydrophobic biocide triclosan by virtue of its markedly permeable outer membrane, while the nosocomial pathogen Pseudomonas aeruginosa is intrinsically resistant to levels far exceeding the triclosan aqueous solubility limit. Widespread incorporation of triclosan in health and personal care products has resulted in its concomitant accumulation with metabolites such as methyl triclosan in environmental and biological systems. The present study was undertaken to investigate the possibility that methylation of triclosan may mitigate its antiseptic efficacy in healthcare settings, as well as represent a potential resistance mechanism. Comparative standardised disc agar diffusion and batch cultural turbidimetric bioassays were employed to assess the relationship between triclosan-susceptible or -resistant bacteria and methyl triclosan. A wild-type P. aeruginosa parental strain and a mutant exhibiting a permeable outer cell envelope phenotype were examined in concert with a refractory wild-type strain sensitised to triclosan susceptibility using outer membrane permeabiliser compound 48/80. All organisms examined were resistant to methyl triclosan, and all organisms excluding P. aeruginosa were susceptible to triclosan over a wide concentration range. The permeable outer membrane phenotype in both mutant and chemically sensitised wild-type strains rendered P. aeruginosa susceptible to triclosan, but not to methyl triclosan. These data support the notion that methylation of triclosan renders the compound unable to inhibit the growth of disparate bacterial pathogens in a manner independent of an intact outer membrane. It can also be concluded that biocide modification may contribute to the intrinsic resistance of P. aeruginosa to triclosan.

Face mask use and control of respiratory virus transmission in households

Mask use is associated with low adherence, but adherent mask users are significantly protected against seasonal disease.

Many countries are stockpiling face masks for use as a nonpharmaceutical intervention to control virus transmission during an influenza pandemic. We conducted a prospective cluster-randomized trial comparing surgical masks, non–fit-tested P2 masks, and no masks in prevention of influenza-like illness (ILI) in households. Mask use adherence was self-reported. During the 2006 and 2007 winter seasons, 286 exposed adults from 143 households who had been exposed to a child with clinical respiratory illness were recruited. We found that adherence to mask use significantly reduced the risk for ILI-associated infection, but <50% of participants wore masks most of the time. We concluded that household use of face masks is associated with low adherence and is ineffective for controlling seasonal respiratory disease. However, during a severe pandemic when use of face masks might be greater, pandemic transmission in households could be reduced.

Many countries are stockpiling face masks for use as nonpharmaceutical interventions to reduce viral transmission during an influenza pandemic. We conducted a prospective cluster-randomized trial comparing surgical masks, non–fit-tested P2 masks, and no masks in prevention of influenza-like illness (ILI) in households. During the 2006 and 2007 winter seasons, 286 exposed adults from 143 households who had been exposed to a child with clinical respiratory illness were recruited. Intent-to-treat analysis showed no significant difference in the relative risk of ILI in the mask use groups compared with the control group; however, <50% of those in the mask use groups reported wearing masks most of the time. Adherence to mask use was associated with a significantly reduced risk of ILI-associated infection. We concluded that household use of masks is associated with low adherence and is ineffective in controlling seasonal ILI. If adherence were greater, mask use might reduce transmission during a severe influenza pandemic.

Surgical hand antisepsis: the evidence

For 150 years members of the surgical team have been washing their hands with solutions designed to remove micro-organisms and therefore reduce surgical site infections in patients. This article discusses the evidence surrounding aspects of surgical hand antisepsis.

Chlorhexidine - Pharmacology and Clinical Applications

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.

Surgical hand antisepsis to reduce surgical site infection

BACKGROUND

Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients.

OBJECTIVES

To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005).

SELECTION CRITERIA

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for selection, trial quality and extracted data.

MAIN RESULTS

Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.

AUTHORS' CONCLUSIONS

Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.

Principles of a clean operating room environment

Optimizing the operating room environment is necessary to minimize the prevalence of arthroplasty infection. Reduction of bacterial contamination in the operating room should be a primary focus of all members of the operating room team. However, in recent years, there has been a decline in the emphasis of the basic principles of antisepsis in many operating rooms. The purpose of this review is to highlight important considerations for optimizing the operating room environment. These principles should be actively promoted by orthopedic surgeons in their operating rooms as part of a comprehensive approach to minimizing arthroplasty infection.

Surgical hand scrubs in relation to microbial counts: systematic literature review

AIM

This paper reports a systematic review whose objective was to determine the effectiveness of surgical hand scrubs in relation to bacterial growth on the hands of operating room staff members.

BACKGROUND

Despite the need for surgical hand scrubs, evidence shows that frequent and prolonged use of antiseptics and brushes may damage the skin. Consequently, lesions may appear, become more heavily colonized by microorganisms and increase the risk of transmitting infection to patients. Recommendations about surgical hand scrubs vary widely and their effectiveness in relation to microbial counts is unknown.

METHOD

A variety of healthcare databases were searched covering the period between January 1990 and December 2004. Based on selection criteria, the abstracts of studies identified were checked to determine whether they fulfilled the inclusion criteria. All studies were assessed as having adequate methodological quality. Using Cochrane Review Manager 4.2 software, weighted mean difference and 95% confidence intervals were calculated.

FINDINGS

Three studies were included in this review. Two studies compared the effectiveness of surgical hand scrubs using an alcohol-based product and a 6-minute scrub using 4% chlorhexidine gluconate; meta-analysis showed a statistically significant difference (weighted mean difference = -0.63, 95% confidence intervals = -0.99 to -0.27, P = 0.0006). One study compared the effectiveness of 2- and 3-minute surgical hand scrubs using 4% chlorhexidine gluconate; meta-analysis showed no difference (weighted mean difference = 0.29, 95% confidence intervals = -0.13 to 0.71, P = 0.18).

CONCLUSION

Surgical hand scrubs using an alcohol-based product were more effective than a 6-minute scrub using 4% chlorhexidine gluconate. There is no evidence to support a 2-minute surgical hand scrub as being more effective than a 3-minute one using 4% chlorhexidine gluconate.

A survey of the appropriate use of antiseptic agents in the operating room of several key health care facilities. A comparison between surveys in 2000 and 2004

Since 2000, new hand and environmental hygiene guidelines have been published by the Center for Disease Control and Prevention (CDC) based on scientific evidence. Accordingly, we expected that the use of disinfectants in clinical settings had been changed. To compare the use and amount of disinfectants before and after the publication of these guidelines, we conducted a questionnaire-based survey on the use of antiseptic agents in operating rooms (ORs) in 6 key hospitals over a period of a month in 2000 and 2004. As a result, the amount of disinfectants used in ORs was reduced in all hospitals in 2004. Especially, amphoteric detergents and glutaral products showed significant reductions in the total amount used in the 6 hospitals, by 94.8 and 96.8%, respectively. The use of povidone-iodine (PVP-I) was decreased by 23.4% overall, although it was increased in 3 hospitals by 11.0-58.6%. The number of applications of PVP-I on the surgical site did not change; however, the site was left to dry without wiping after PVP-I application more frequently in 2004 than in 2000. The time for surgical scrubbing was shortened in 2004, but brush scrubbing was still used as often as in 2000. Many of the hospitals used brush scrubbing in conjunction with alcohol-based rubs. These results indicated changes in infection control measures in hospital settings after publication of the new CDC guidelines; environmental disinfection had been limited and excessive use of disinfectants reevaluated.

Comparison of the Antimicrobial Efficacy of Povidone-Iodine, Povidone-Iodine-Ethanol and Chlorhexidine Gluconate-Ethanol Surgical Scrubs

BACKGROUND

Scrubbing of the hands and forearms with a brush and antiseptic agents has been the standard for surgical practice. However, it has been increasingly recognized that brush scrubbing may provoke side effects and that an alcohol-based hand antiseptic used in conjunction with a scrub agent enhances the effectiveness. In this study, two types of alcohol-based agents were used after a povidone-iodine (PVP-I) scrub and compared for their effectiveness.

MATERIALS AND METHODS

The study was conducted as a crossover trial with 20 volunteers. After hand rubbing with PVP-I, either PVP-I-ethanol rubbing or chlorhexidine gluconate-ethanol (CHG-ethanol) rubbing was used for surgical hand cleansing. Samples were collected by the modified glove juice method to count bacteria on hands.

RESULTS

In both groups, the bacterial count was significantly reduced after handwashing (p < 0.001), and the reduction was still significant after 2 h (p < 0.001 for PVP-I-ethanol and p < 0.002 for CHG-ethanol). The log(10) reduction factor (RF) in the PVP-I-ethanol group was significantly higher than that in the CHG-ethanol group immediately after handwashing (p < 0.001) but significantly lowered after 2 h (p < 0.01) to the level similar to that of CHG-ethanol. Although RF was lower in the CHG-ethanol group immediately after and 2 h after handwashing compared to the PVP-I-ethanol group, it did not decrease with time.

CONCLUSION

Brushless surgical scrubbing with PVP-I-ethanol or CHG-ethanol in conjunction with PVP-I showed antiseptic effects immediately after and 2 h after handwashing. RF immediately after handwashing was significantly higher with PVP-I-ethanol compared to CHG-ethanol, but it was similar in both groups after 2 h. These results suggest that when used in combination with a PVP-I scrub, an alcohol-based hand antiseptic containing the same active agent (PVP-I in this study) has a powerful antiseptic effect; however, when it contains different antiseptic agents (i.e. CHG in this study), it should be selected carefully based on its antiseptic property.

Evaluation of Tap Water for Surgical Handwashing

PURPOSE

In Japan, sterile water is used for rinsing in surgical handwashing, whereas in Western countries tap water is generally used. We conducted this study to examine the conditions and the equipment that affect bacterial contamination in tap water and to determine whether the tap water in our institute is suitable for surgical handwashing.

METHODS

First, we examined the water pipes and measured the free chlorine content in the tap water in the operating room. Next, we recruited 40 volunteers and conducted preliminary tests with sterile water. Thirty of these subjects participated in a handwashing test using tap water.

RESULTS

The mean free chlorine levels in the tap water and the sterile water were 0.30 +/- 0.05 and 0.07 +/- 0.03 mg/l, respectively. The handwashing test using tap water showed immediate, persistent, and cumulative bacteria activity within the minimum limits set by the Food and Drug Administration (FDA).

CONCLUSION

The free chlorine levels in the tap water in our institute satisfied Japanese health regulations. Moreover, the handwashing test met the criteria of the FDA. Thus, we conclude that this tap water is safe to use for rinsing in surgical handwashing.

Hand hygiene: an evidence-based review for surgeons

This review of the literature discusses the scientific evidence behind using different hand hygiene agents on the surgical ward, and in theatre for preoperative disinfection. It considers the mechanism of action of the agents and their effectiveness against different pathogens, as well as possible future agents, and how they are tested. It addresses problems such as the poor compliance with hand hygiene guidelines by healthcare workers (especially doctors) and investigates what can be done to improve compliance. Finally, it demonstrates the reduction in hospital acquired infection (HAI) rate that can be achieved by improving hand hygiene compliance, and shows that the savings associated with this easily outweigh the cost.

Hand hygiene: simple and complex

This review gives an overview of hand hygiene in healthcare and in the community, including some aspects which have attracted little attention, such as hand drying and cultural issues determining hand hygiene behaviour. Hand hygiene is the most effective measure for interrupting the transmission of microorganisms which cause infection both in the community and in the healthcare setting. Using hand hygiene as a sole measure to reduce infection is unlikely to be successful when other factors in infection control, such as environmental hygiene, crowding, staffing levels and education are inadequate. Hand hygiene must be part of an integrated approach to infection control. Compliance with hand hygiene recommendations is poor worldwide. While the techniques involved in hand hygiene are simple, the complex interdependence of factors which determine hand hygiene behaviour makes the study of hand hygiene complex. It is now recognised that improving compliance with hand hygiene recommendations depends on altering human behaviour. Input from behavioural and social sciences is essential when designing studies to investigate compliance. Interventions to increase compliance with hand hygiene practices must be appropriate for different cultural and social needs. New strategies to promote hand hygiene worldwide include the formation of public-private partnerships.

General principles of surgery applied to cattle

Basic principles of surgery are important to review, even for experienced surgeons. Although aseptic surgical principles are not always applicable in the field, we have to respect some guidelines. Recent research will influence the way that we do things, based on what we have been taught and our experience. Respecting those simple principles can make a big difference in the final outcome.