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

Comparative antimicrobial efficacy of 4 surgical hand-preparation procedures prior to application of an alcohol-based hand rub in veterinary students

OBJECTIVE

To determine the influence of skin preparations before application of an alcohol-based hand rub (ABHR) on bacterial counts before and after elective surgery.

STUDY DESIGN

Clinical prospective study.

SAMPLE POPULATION

Veterinary students (n = 103) performing ovariohysterectomies on 140 dogs.

METHODS

Participants were randomly assigned to 1 initial surgical preparation on the day of surgery: A - hand preparation with medicated solution (4% w/v chlorhexidine bigluconate followed by an ABHR; B - application of a medication solution (benzalkonium chloride 0.1%-1% and polymeric biguanide hydrochloride 0.01%-0.1%) followed by an ABHR; C - nonmedicated pH-neutral soap hand wash followed by ABHR, and D - direct application of an ABHR. Samples were taken by pressing the distal finger tips to an agar plate before the hand preparation, after the hand preparation (n = 3), after ABHR application, and 120 minutes later. Colony-forming units (CFUs) for samples were determined. Total log CFU and CFU log10 reduction were calculated and used for comparison with P < .05.

RESULTS

Two hours after surgery commenced, the participants of groups that performed a hand preparation had lower total CFUs than those that did not perform a hand preparation (P = .001). In particular, the number of CFUs was lower when ABHR was performed after application of pHN compared to direct ABHR (P = .001).

CONCLUSION

In this population, performing a hand preparation with pHN prior to applying an ABHR had better antimicrobial effect for the duration of surgery than not performing a hand preparation.

CLINICAL SIGNIFICANCE

Surgeons should wash their hands prior to ABHR before starting their first surgery of the day, even when hands appear clean.

Comparative efficacy of 0.2% chlorhexidine and 10% Betadine for perioral skin disinfection prior to oral surgical procedures: a clinical trial

BACKGROUND

Surgical site infection (SSI) is a possible postoperative complication. Preoperative application of antiseptics on the surgical site can decrease the rate of SSIs.

AIM

This study aimed to compare the efficacy of 0.2% chlorhexidine (CHX) and 10% Betadine (povidone-iodine) for perioral skin disinfection prior to oral surgical procedures.

METHODS

This clinical trial (IRCT20181017041365N1) (registration date: 2019/05/04) evaluated 57 male patients who were randomly selected among those presenting to the Periodontology Department of Ahvaz Jundishapur University. Baseline microbial samples were collected from the perioral skin at the right and left sides of the face in each patient by sterile swabs. Next, the perioral area was disinfected with 10% Betadine in the right side and 0.2% CHX in the left side. Secondary microbial samples were then collected. Wilcoxon matched-pairs signed-ranks and Mann-Whitney test were used to compare the colony counts. The significance level was set at p ≤ 0.05. Data were analyzed with the Stata program, version15.1.

RESULTS

The bacterial colony count was 3147 (314,700) in the Betadine and 3139 (313,900) in the CHX group at baseline (P = 0.86). These values changed to 1196 (119,600) in the Betadine (P < 0.001) and 857 (85,700) in the CHX (P < 0.001) group after disinfection. A significant difference was found in colony count between the CHX and Betadine groups after intervention (P = 0.0001).

CONCLUSION

According to the results, 0.2% CHX has higher antimicrobial efficacy than 10% Betadine for perioral disinfection prior to oral surgical procedures.

TRIAL REGISTRATION

IRCT20181017041365N1. Registered on 2019/05/04.

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.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Presence of Qac genes in clinical isolates of methicillin-resistant and methicillin-susceptible Staphylococcus pseudintermedius and their impact on chlorhexidine digluconate susceptibility

OBJECTIVE

To evaluate the presence of quaternary ammonium compound (QAC) (resistance genes, qac A/B, smr, qacG, and qacJ, in clinical isolates of methicillin-susceptible Staphylococcus pseudintermedius (MSSP) and methicillin-resistant S pseudintermedius (MRSP) from dogs and the impact on in vitro chlorhexidine susceptibility.

STUDY DESIGN

Experimental in vitro study.

SAMPLE POPULATION

Seventy isolates from dogs colonized or infected with MRSP (n = 50) or MSSP (n = 20).

METHODS

Agar dilution was used to determine the minimum inhibitory concentration (MIC) of chlorhexidine digluconate. Real-time polymerase chain reaction was used to detect the presence of QAC resistance genes, qacA/B, smr, qacG, and qacJ genes.

RESULTS

One or more qac genes were identified in 52 of 70 (74%) isolates. Overall, there was no association between chlorhexidine MIC and the presence of one or more qac genes (P = .85) or the presence of qacA/B (P = .31), smr (P = .72) or qacJ (P = .93) individually. There was an association between qacG and MIC (P = .012), with a median MIC of 1.5 μg/mL for isolates possessing this gene and 1 μg/mL for those not possessing it.

CONCLUSION

Quaternary ammonium compound resistance genes were present in MRSP and MSSP isolates. With the exception of qacG, the presence of these genes was not associated with increased MIC. All isolates exhibited MIC 5000 to 80 000 times lower than the concentration recommended for use.

CLINICAL SIGNIFICANCE

Despite the presence of QAC genes, chlorhexidine digluconate should be effective against MRSP and MSSP if used correctly.

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.

Alcohol-based surgical hand preparation: translating scientific evidence into clinical practice

Background

Although alcohol-based surgical hand preparation offers potential advantages over the traditional surgical scrubbing technique, implementing it may be challenging due to resistance of surgeons in changing their practice. We aimed to implement alcohol-based surgical hand preparation in the hospital setting evaluating the impact of that on the quality and duration of the procedure, as well as on the prevention of surgical site infections.

Methods

A quasi-experimental study conducted at a tertiary-care university hospital from April 01 to November 01, 2017. Participants were cardiac and orthopedic surgical teams (n = 56) and patients operated by them (n = 231). Intervention consisted of making alcohol-based handrub available in the operating room, convincing and training surgical teams for using it, promoting direct observation of surgical hand preparation, and providing aggregated feedback on the quality of the preparation. The primary study outcome was the quality of the surgical hand preparation, inferred by the compliance with each one of the steps predicted in the World Health Organization (WHO) technique, evaluated through direct observation. Secondary study outcome was the patient’s individual probability of developing surgical site infection in both study periods. We used the Wilcoxon for paired samples and McNemar’s test to assess the primary study outcome and we build a logistic regression model to assess the secondary outcome.

Results

We observed 534 surgical hand preparation events. Among 33 participants with full data available for both study periods, we observed full compliance with all the steps predicted in the WHO technique in 0.03% (1/33) of them in the pre-intervention period and in 36.36% (12/33) of them in the intervention period (OR:12.0, 95% CI: 2. 4-59.2, p = 0.002). Compared to the pre-intervention period, the intervention reduced the duration of the preparation (4.8 min vs 2.7 min, respectively; p < 0.001). The individual risk of developing a surgical site infection did not significantly change between the pre-intervention and the intervention phase (Adjusted RR = 0.66; 95% CI 0. 16-2.70, p = 0.563).

Conclusion

Our results demonstrate that, when compared to the traditional surgical scrub, alcohol-based surgical hand preparation improves the quality and reduces the duration of the preparation, being at least equally effective for the prevention of surgical site infections.

Chlorhexidine is not an essential component in alcohol-based surgical hand preparation: a comparative study of two handrubs based on a modified EN 12791 test protocol

BACKGROUND

Surgical hand preparation is an essential part of modern surgery. Both alcohol-based and antiseptic detergent-based hand preparation are recommended practices, with a trend towards use of alcohol based handrubs. However, discussion has arisen whether chlorhexidine is a required ingredient in highly efficacious alcohol-based formulations, in view of providing sustained antimicrobial efficacy.

METHODS

One alcohol-only formulation (product A), containing ethanol and n-propanol, and one formulation containing a chlorhexidine-ethanol combination (product B) were directly compared with each other using a modified test protocol based on European standard EN 12791 (2016) with 25 volunteers. The alcohol-only formulation (product A) was applied for only 90 s, the chlorhexidine-alcohol formulation (product B) for 180 s. Microbial log reduction factors were determined and statistically compared immediately after application and at 6 h under surgical gloves.

RESULTS

The alcohol-only formulation (product A) achieved mean log reduction factors of 1.96 ± 1.06 immediately after application and 1.67 ± 0.71 after 6 h. The chlorhexidine-alcohol combination (product B) achieved mean log reduction factors of 1.42 ± 0.79 and 1.24 ± 0.90 immediately and after 6 h, respectively. The values for product A were significantly greater than those for product B at both measured time points (p ≤ 0.025 immediately after application and p ≤ 0.01 after 6 h).

CONCLUSIONS

An optimized alcohol-only formulation tested according to a modified EN 12791 protocol in 25 healthy volunteers outperformed a chlorhexidine-alcohol formulation both immediately after application and at 6 h under surgical gloves, despite a much shorter application time. Thus, optimized alcohol-only formulations do not require chlorhexidine to achieve potent immediate and sustained efficacy. In conclusion, chlorhexidine is not an essential component for alcohol-based surgical hand preparation.

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

The impact of surgical hand antisepsis technique on surgical site infection

BACKGROUND

Limited evidence exists regarding the effect on superficial and deep incisional surgical site infections (SDSSIs) of alcohol-based hand rubs (ABR) versus traditional aqueous surgical scrubs (TSS). User preferences and practice are unknown.

METHODS

A retrospective cohort study examining SDSSIs using VA Surgical Quality Improvement Program cases before ABR implementation (2007-2009, TSS group) and after (2013-2014, ABR group). A descriptive survey.

RESULTS

SDSSI rates were 1.8% and 1.5% for TSS (n=4051) and ABR (n=2293), respectively (p=0.31). The adjusted odds of SDSSI using ABR was not significant (OR 0.82; 95% CI, 0.51-1.32). Greatest SDSSI risk was from preoperative radiotherapy (OR, 2.78; 95% CI, 1.14-6.78), general surgery (OR, 2.39; 95% CI, 1.30-4.39) and preoperative smoking (OR, 1.58; 95% CI, 1.02-2.44). Of 95 surveys included, 52% favored ABR. Although 95% self-reported correct product application, improper duration was revealed in both groups (TSS 18% and ABR 10%).

CONCLUSIONS

Implementation of an ABR for use in surgical hand antisepsis did not alter SDSSI rates. Improving product knowledge and compliance may improve SSI rates.

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.

Antibacterial effects on dry-fast and traditional water-based surgical scrubbing methods: a two-time points experimental study

This study determined the in-use effects of dry-fast and traditional hand-washing surgical scrubs among operating room staff members. This is a static group comparison study with purposive sampling. A total of 156 staff members were recruited in an operating room in a medical center located in southern Taiwan. The participants were divided into traditional and dry-fast hand-washing groups. Microbial counts were measured right after the two groups finished surgical scrubbing and at the completion of surgery. The results showed that the use of dry-fast antisepsis has a better persistent effect (P = 0.001), more nurses chose dry-fast antisepsis than surgeons (P = 0.012), and the post-operation number of colonies for nurses was significantly higher than that for surgeons (P = 0.003). Operating room nurses are long-term and frequent users of antibacterial agents, and their requirement of skin protection is higher. The dry-fast technique has the advantage of being less irritating to the skin and less time consuming; therefore, brush-free and dry-fast antisepsis is recommended.

Patient safety in the operating room: I. Preoperative

BACKGROUND

Beyond the controlled trauma of surgery, the operating room can be a hazardous place for patients and health care workers alike. Modern plastic surgery requires a thorough knowledge of various perioperative risks and methods to minimize these risks. As the importance of teamwork becomes more evident, clear communication skills preoperatively, intraoperatively, and postoperatively become equally critical. To facilitate an improvement in perioperative patient safety, this article will review aspects of communication, including crew resource management, root cause analysis, and surgical-site verification. In addition, the authors will discuss patient positioning, antiseptic hand and patient preparations, and barriers, such as surgical scrubs, gowns, gloves, and drapes.

METHODS

The authors reviewed the literature regarding operating room safety, both primary research and secondary reviews, via multiple PubMed queries and literature searches. Topics most relevant to inpatient plastic surgery were included in the final analysis and summarized, as a full review of each topic is beyond the scope of this article.

RESULTS

Many possible interventions were identified, with the goal of reducing perioperative complications, such as wrong site surgery, neuropathies, myopathies, compartment syndromes, pressure ulcers, surgical-site infections, and blood-borne disease transmissions among plastic surgeons and their patients.

CONCLUSIONS

There are ample opportunities for the reduction of preventable adverse events in plastic surgery. This article aims to provide its reader with the tools to research adverse events and a basic education in avoiding specific preoperative events. A second article addressing intraoperative and postoperative patient safety follows.

Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts

BACKGROUND

Although the surgical scrub is a mandatory and routine procedure, there is no standard recommendation for nail cleaning during the scrub. This study compared the efficacy of nail picks and brushes used for nail cleaning during the surgical scrub in reducing bacterial counts.

METHODS

Sixty circulatory nurses were included in the survey. The nurses were randomized to undertake 1 of 3 surgical hand scrub protocols: using surgical scrub alone (control group), using a nail pick during the surgical scrub, or using a brush during the surgical scrub. Bacterial counts were measured on the dominant hand immediately before the scrub and 1 hour after the scrub using the glove juice method.

RESULTS

The bacterial counts at 1 hour after the surgical scrub were lower in the control group than in the 2 intervention groups, and there was no significant difference between the 2 intervention groups (F = 2.063; P = .136; P > .05).

CONCLUSION

Using nail picks and brushes on nails during the surgical scrub does not provide additional decontamination.

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.

Eficácia de três métodos de degermação das mãos utilizando gluconato de clorexidina degermante (GCH 2%)

A degermação cirúrgica das mãos e dos antebraços é um procedimento que integra as atividades de paramentação cirúrgica como uma medida de prevenção de infecção do sítio cirúrgico. Com o advento dos princípios antissépticos degermantes, a necessidade do uso de escovas para a degermação cirúrgica tem sido questionada e recomendado o abandono deste uso devido às lesões provocadas na pele. Com a finalidade de fundamentar a eficácia da técnica da degermação cirúrgica sem o uso de escovas ou esponjas, o objetivo deste estudo foi avaliar três métodos para degermação cirúrgica utilizando a formulação degermante de gluconato de clorexidina - GCH 2%: com escova, com esponja e sem artefato. Foram avaliados 29 profissionais da saúde, utilizando o método de caldo de luva para coleta de micro-organismos antes e depois de cada método testado. As análises estatísticas comprovaram não haver diferenças estatísticas significantes na redução microbiana entre os três métodos analisados (p=0,148), o que teoricamente descarta a necessidade da continuidade do uso de escovas e esponjas para a realização da degermação das mãos.

A review of hand-washing techniques in primary care and community settings

AIM

This review seeks to identify the most effective hand-washing and hand-cleansing practice that could be used in primary care.

BACKGROUND

Healthcare associated infection is a major problem in the UK causing 5000 deaths every year. Current guidelines indicate expert opinion is the level of evidence for hand washing as an activity to reduce infection.

DESIGN

Systematic review.

METHOD

Publications on hand-washing, hand-cleansing studies, policy and practice-based documents were sought by searching several databases. Terms used included hand washing, hand cleansing, hand hygiene, hand decontamination, infection control and primary care.

RESULTS

Few articles described the hand-washing technique in detail and some publications simply referred to either the European and British Standards or the Centre for Disease Control statement on hand washing. Major discrepancies in hand position and water flow direction were found. Several methodological problems were also identified and few studies were undertaken in primary care.

CONCLUSION

This review has found a lack of evidence for hand-washing techniques being undertaken in practice today. Findings from hand-washing technique studies were inconclusive and methodological issues exist resulting in sparse reliable evidence. There is an urgent need to undertake methodologically sound studies of hand-washing techniques for use in the ever expanding scope of primary care practice.

RELEVANCE TO CLINICAL PRACTICE

Evidence for hand-washing and hand-cleansing techniques will inform healthcare professional practice, and contribute to the overall management of infection control in primary care.

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.

Does Preoperative Topical Antimicrobial Scrub Reduce Positive Surgical Site Culture Rates in Men Undergoing Artificial Urinary Sphincter Placement?

PURPOSE

We determined if the incidence of a perioperative surgical site-positive culture was reduced by a 5-day topical antimicrobial scrub before implantation of an artificial urinary sphincter.

MATERIALS AND METHODS

A single surgeon prospective cohort study was conducted of 100 consecutive artificial urinary sphincter implants placed between May 2003 and November 2005. We compared 50 men who performed preoperative topical antimicrobial scrub with 4% chlorhexidine to the abdominal site and perineal site with 50 men who used their normal hygiene (soap and water). All received povidone-iodine skin disinfection before incision, and bacterial cultures of the abdominal and perineal sites were collected immediately after skin disinfection and after artificial urinary sphincter implantation. Baseline comparisons between groups were done with the Wilcoxon rank sum and Fisher exact tests. Predictors of positive culture were identified using multivariate logistic regression analysis.

RESULTS

The causes of incontinence were radical prostatectomy (90), radiation therapy (8) and transurethral resection of the prostate (2). There were no baseline differences between the groups including age, diabetes or previous urethral surgery. Overall 140 of the 400 cultures were positive with only 37% of the positive cultures (52 of 140) observed with topical antimicrobial scrub. For the perineal site the only factor affecting preoperative culture status was topical antimicrobial scrub (OR 0.23, p = 0.003). A positive postoperative culture was predicted by a positive preoperative perineal (OR 4.61, p = 0.003) and abdominal culture (OR 3.80, p = 0.013).

CONCLUSIONS

Preoperative topical antimicrobial scrub resulted in a 4-fold reduction in preoperative perineal colonization rate and overall reduction in positive surgical site cultures. Given the low cost, safety and efficacy, topical antimicrobial scrub should be considered before artificial urinary sphincter placement.

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.