Surgical hand antisepsis: the evidence.
Surgical hand antisepsis removes transient micro-organisms and also reduces the number of resident microorganisms. The purpose of this is to minimise the opportunity for patients to develop a surgical site infection.
Detailed information regarding the origins of hand antisepsis seems to be sparse. Hand antisepsis appears to have been introduced around 1860 by Joseph Lister to promote asepsis and reduce surgical site infections in patients. When Lister was Professor of Surgery at the Glasgow Royal Infirmary he recognised the importance of Louis Pasteur's germ theory (decay is caused by micro-organisms and decay can be prevented by killing the organisms) and its application to surgery. He initiated a disinfection regime where the clinical environments and all equipment were cleaned with carbolic acid. Part of the regime included the surgical team washing their hands in a solution of 5% carbolic acid before undertaking surgery.
A second oblique reference to scrubbing is found slightly later in 1889 at the Johns Hopkins Hospital in Baltimore where scrub nurse Caroline Hampton is described washing her hands with a solution of carbolic acid and mercuric chloride.
There are three main developments within surgical hand antisepsis which have occurred relatively recently. These include the removal of scrub brushes, the introduction of alcohol rubs and the reduction in the duration of the scrub. As recently as 2001, instructions for surgical hand antisepsis included scrubbing the hands and arms with a brush (Gardner & Anderson Man 2001), this is presumably where the name 'scrub' comes from. This practice was stopped when studies found that scrubbing hands and arms resulted in skin damage and increased bacterial counts (Loeb et al 1997, Springer 2002). While scrubbing the hands and arms with a brush has been discontinued, brushes are still recommended for using on nails (Mangram et al 1999).
Alcohol rubs were introduced around the late 1990s as an alternative to traditional aqueous based antiseptic solutions. They do not require rinsing and are sometimes referred to as waterless scrubs. They contain an antiseptic agent such as chlorhexidine gluconate in an alcohol solution. As alcohol itself is an antiseptic agent, the additive (i.e. chlorhexidine) is referred to an additional antiseptic agent. Alcohol rubs are said to combine the residual effects of the additional antiseptic agent as well as the rapid killing properties of alcohol (Larson 1995). A national survey in 2006 found that 20% of AfPP members used alcohol rubs (Tanner et al 2007).
The third development within hand antisepsis has been the move towards a shorter duration. Over the past three decades scrubs have gradually reduced from 10 minutes to two minutes (Wheelock & Lookinland 1997). The evidence supporting this move is discussed later in this article.
Table 1 shows the current practice of surgical hand antisepsis recommended by AfPP (AfPP 2007).
The focus of this article
This article presents and discusses the evidence surrounding surgical scrubbing. Three main topics are addressed:
* aqueous scrubs versus alcohol rubs
* chlorhexidine gluconate versus povidone iodine
* the duration of the surgical scrub.
This article is based on the more detailed Cochrane systematic review of surgical hand antisepsis (Tanner et al 2008).
The objective of the search was to identify all randomised controlled trials of surgical hand antisepsis. All included trials had to be clinically based (i.e. conducted in operating theatres using clinical staff as opposed to non-clinical volunteers in laboratory settings) and measure surgical site infections or the number of bacteria on the hands of the surgical team.
The following databases were searched for relevant trials published in any language.
* Cochrane Wounds Group Specialised Register (Searched 12 June 2007)
* CENTRAL--The Cochrane Library Issue 2, 2007
* Ovid MEDLINE--2005 to Week 5, 2007
* Ovid EMBASE--2005 to Week 23, 2007
* Ovid CINAHL--2005 to Week 2, 2007
* ZETOC database of conference proceedings was searched from 1993 to 2005.
In addition, five trial authors were contacted and provided additional information about their studies (Kappstein 1993, Pereira 1997, Herruzo 2000, Sensoz 2003, Hajipour 2006). One study was not published in English and was required to be translated (Kappstein 1993).
Aqueous scrubs versus alcoholic rubs
Five studies compared aqueous scrubs against alcohol rubs (Herruzo et al 2000, Pietsch 2001, Parienti et al 2002, Hajipour et al 2006, Gupta et al 2007). The five trials used different antiseptic solutions, therefore it was not appropriate to perform a meta analysis (A meta analysis is a research method where similar studies are grouped together to allow statistical tests to be conducted). In the absence of a meta analysis each trial is discussed separately.
Parienti et al (2002) compared a five minute scrub using either 4% povidone iodine (Betadine) or 4% chlorhexidine gluconate (Hibiscrub) against a five minute hand rub using 75% propanol-1, propanol-2 with mecetronium ethylsulfate (Sterillium). Participants in the aqueous scrub group were allowed to choose between chlorhexidine gluconate or povidone iodine scrubs. Participants in the hand rubbing group carried out a single hand wash for one minute with nonantiseptic soap at the start of each day.
Six hospitals were randomised to use one of the two interventions. The intervention was used for one month and at the end of the month each hospital switched to the alternative intervention. The trial ran for 16 months swapping between groups every month. The entire scrub team in each hospital took part. 4,387 consecutive patients undergoing clean and clean contaminated surgery were included in the trial. Surgical site infection (SSI) was assessed at 30 days using the universally accepted definition from the Centres for Disease Control (Mangram et al 1999). Of all the studies on surgical hand antisepsis this trial satisfies the most quality criteria:
* Random number tables were used to generate the randomisation sequence.
* A priori sample calculation was conducted.
* The primary outcome (surgical site infection) was measured.
* Exclusion criteria are listed and an intention to treat analysis was carried out.
This is the most important trial to be conducted on surgical scrubbing.
Parienti found no statistically significant difference in the number of surgical site infections: 2.5% (53/2135) patients developed infections in the aqueous scrub group compared with 2.4% (55/2252) in the hand rub group.
Herruzo et al (2000) compared three intervention groups: chlorhexidine gluconate scrub, povidone iodine scrub and an alcohol rub with N-duopropenide. Each scrub or rub lasted three minutes. One hundred and fifty four members of the surgical team were randomised for 55 operations. Colony forming units (the number of bacteria) on the hands of the surgical team were measured before antisepsis, immediately after antisepsis and at the end of the surgical procedure.
For the comparison of aqueous chlorhexidine scrub against Nduopropenide rub, Herruzo reports Nduopropenide is statistically significantly more effective than chlorhexidine in reducing the number of colony forming units on participants' hands immediately after antisepsis and at the end of a surgical procedure.
For the comparison of aqueous povidone iodine scrub against N-duopropenide rub, Herruzo reports that N-duopropenide is statistically significantly more effective than chlorhexidine in reducing the number of colony forming units on participants' hands immediately after antisepsis and at the end of a surgical procedure.
Pietsch 2001 compared scrubbing using 4% chlorhexidine gluconate (Hibiscrub) with hand rubbing using an alcoholic solution of 45% propanol-2, 30% propanol1 plus 0.2% ethylhexadecyldimethyl ammonium ethylsulfate (Sterillium). Seventy-five surgeons in one hospital participated in this randomised crossover trial using one product for four weeks then changing to the alternative product following a rest week. Colony forming units were measured before antisepsis, immediately after antisepsis and after the surgical procedure.
Rubbing using 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate (Sterillium) was found to be more effective than scrubbing using 4% chlorhexidine gluconate in reducing colony forming units on participants hands immediately after antisepsis and at the end of the surgical procedure.
Hajipour et al 2006 compared a three minute 4% chlorhexidine gluconate scrub with a three minute chlorhexidine in alcohol rub (Hydrex). Following an aqueous chlorhexidine scrub at the start of each day, four surgeons were randomised a total of 53 times to either the chlorhexidine aqueous scrub or the chlorhexidine in alcohol rub. Testing was carried out using the finger press method at the end of each surgical procedure. Colony forming units were statistically significantly higher in the alcohol rub group showing the aqueous scrub to be more effective. The findings of this trial are limited as the study design is weak: the four participants, who were not blinded, were repeatedly randomised a total of 53 times and the finger press method is not the recognised testing method.
Gupta et al 2007 compared 7.5% povidone iodine aqueous scrub against two alcohol rubs: three 2ml aliquots of 1% chlorhexidine gluconate in 61% ethyl alcohol (Avagard) and a three minute application of zinc pyrithione in 70% ethyl alcohol (Triseptin). No further details are provided regarding the application of the products. Eighteen operating room staff used each of the three products for five consecutive days. Testing was carried out immediately before and after antisepsis on day one, and at the end of days two and five.
When colony forming units were compared collectively from all the sample times, Gupta found no statistical significant difference between the solutions.
The findings from these five studies raise an interesting observation. The four studies by Gupta, Hajipour, Herruzo and Pietsch measuring colony forming units suggest overall that alcohol rubs are more effective than aqueous scrubs. However these four studies are superseded by Parienti's trial which measured the primary outcome: surgical site infection. Parienti found no difference between alcohol rubs or aqueous scrubs in relation to surgical site infections. Therefore alcohol rubs are acceptable alternatives to aqueous scrubs.
It is worth noting that in these four studies (Herruzo et al 2000, Pietsch 2001, Parienti et al 2002, Gupta et al 2007) alcohol rubs were used for the first wash of the day following a simple hand wash with soap. This is important to point out as the AfPP (2007) guidelines state that alcohol rubs are an acceptable alternative to scrubbing for repeated washings only.
Chlorhexidine gluconate versus povidone iodine
The American, Australian and British recommendations for surgical hand antisepsis all state that the antiseptic solution used 'should meet general criteria for antiseptics' (ACORN 2004, AfPP 2007, AORN 2007). The general criteria are that the antiseptic is fast acting, has a broad spectrum of activity and provides a residual effect. Therefore no organisation recommends the use of one antiseptic over another. A survey of AfPP members (Tanner et al 2007) found that the most widely used antiseptic was chlorhexidine gluconate (49%) followed by povidone iodine (35%).
Four studies compared chlorhexidine gluconate with povidone iodine (Pereira et al 1990, Pereira et al 1997, Herruzo et al 2000, Furukawa et al 2005). It was not possible to combine these studies into a meta analysis as different antisepsis protocols were used.
Pereira (1990) compared 4% chlorhexidine gluconate (Hibiclens) with 7% povidone iodine (Betadine) using a five minute initial and three minute subsequent scrub. Thirty-four participants were randomly assigned to one of four groups and each group was assigned to one of four interventions each lasting one week. Participants were anaesthetic, recovery and ward staff rather than scrub staff, who rotated through each of the interventions. Hand bacterial samples were taken immediately after the initial scrub, two hours after the initial scrub and two hours after the subsequent scrub. Chlorhexidine was significantly more effective than povidone iodine in reducing the number of colony forming units immediately after scrubbing, two hours after the initial scrub and two hours after the subsequent scrub.
In the same study described above Pereira (1990) compared 4% chlorhexidine gluconate (Hibiclens) with 7% povidone iodine (Betadine) using a three minute initial and 30 second subsequent scrub. There was no significant difference in colony forming units immediately after scrubbing. There were significantly fewer colony forming units in the chlorhexidine group compared with the povidone iodine group two hours after the initial scrub and two hours after the subsequent scrub.
Furukawa (2005) compared 4% chlorhexidine gluconate (Hibiscrub) with 7.5% povidone iodine (Isodine) using a three minute scrub. Twenty-two scrub nurses were randomised to one of the two intervention groups. Each nurse took part only once. The nurses did not take part in any actual surgery. Hand bacterial samples taken before and after the scrub showed there were significantly fewer colony forming units in the chlorhexidine gluconate group after scrubbing.
Herruzo (2000) compared three intervention groups: aqueous chlorhexidine gluconate 4%, aqueous povidone iodine 7.5% and an alcohol rub with N-duopropenide. Each scrub or rub lasted three minutes. One hundred and fifty four members of the surgical team were randomised for 55 operations. Colony forming units were measured before antisepsis, immediately after antisepsis and at the end of the surgical procedure. A three minute aqueous scrub using chlorhexidine gluconate was found to be significantly more effective in reducing colony forming units on hands than a three minute aqueous scrub using povidone iodine immediately after antisepsis and at the end of a surgical procedure.
Pereira (1997) compared 4% chlorhexidine gluconate (Hibiclens) with 5% povidone iodine plus 1% triclosan (Microshield PVP) using a three minute initial and two and a half minute subsequent scrub. Twenty-three operating room nurses were randomised to carry out each of five interventions for one week each. Participants did not take part in any actual surgery. Hand bacterial samples were carried out immediately after the first antisepsis, two hours after the first antisepsis and two hours after the subsequent antisepsis.
No statistically significant differences in the number of colony forming units were found immediately after the first antisepsis or two hours after the first antisepsis. A statistically significant difference in favour of chlorhexidine was found two hours after the subsequent antisepsis.
Overall these studies show that chlorhexidine gluconate scrub is more effective than a povidone iodine scrub. However, there is one major limitation with these studies which means we must be cautious when interpreting the findings for use in practice. From these findings we could conclude that chlorhexidine gluconate should be used in preference to povidone iodine. However all of these studies measured the number of bacteria on hands rather than the number of surgical site infections in patients. We do not know what the relationship is between bacteria on hands and surgical site infections in patients. Increased bacteria on hands may result in more surgical site infections, or it may have no impact at all. Therefore the only recommendation for practice we may claim is to tentatively suggest that chlorhexidine gluconate might be used in preference to povidone iodine.
Duration of application
Four trials compared surgical antisepsis of different durations (Kappstein et al 1993, Pereira et al 1990, Pereira et al 1997, Wheelock et al 1997). The four trials were of different durations and used different antiseptic agents so it was not possible to perform a meta analysis, each trial is discussed separately.
Kappstein (1993) compared a five minute rub with a three minute rub using 'alcoholic disinfectant'. The disinfectant is not identified. Both rubs follow one minute hand washes using soap and water. Twenty-four surgeons carried out each of three intervention groups once in a random order. Samples were taken before and immediately after antisepsis. Immediately after antisepsis there were significantly fewer colony forming units after the shorter three minute rub than after the five minute rub. Following a one minute hand wash a three minute rub appears to be more effective than the five minute rub.
Pereira (1990) compared a five minute initial and three minute subsequent scrub with a three minute initial and 30 second subsequent scrub using chlorhexidine gluconate. Thirty-four participants were randomly assigned to one of four groups and each group was assigned to one of four interventions each lasting one week.
There was no difference in the number of colony forming units for either duration of scrub immediately after the initial scrub or two hours after the initial scrub. However, significantly more colony forming units were found two hours after the subsequent scrub when using the 30 second subsequent scrub compared with the three minute subsequent scrub. This shows a 30 second subsequent scrub was less effective than a three minute subsequent scrub with chlorhexidine in reducing the number of colony forming units.
In the same trial Pereira (1990) compared a five minute initial and three minute subsequent scrub with a three minute initial and 30 second subsequent scrub using povidone iodine. There was no difference in the number of colony forming units immediately after the initial scrub or two hours after the initial scrub when using povidone iodine for either a five or a three minute regimen. Therefore there is no difference in colony forming units between a five minute and a three minute initial scrub when using povidone iodine. There was no difference in the number of colony forming units two hours after the subsequent scrub for either a three minute or a 30 second regimen. Therefore there is no difference in colony forming units on hands between a three minute and a 30 second scrub for subsequent scrubs when using povidone iodine.
Pereira (1997) compared a five minute initial and a three and a half minute subsequent scrub with a three minute initial and a two and a half minute subsequent scrub using 4% chlorhexidine gluconate. Twenty-three operating room nurses were randomised to carry out each of five interventions for one week each.
No statistically significant differences in the number of colony forming units were found on participants' hands immediately after the initial antisepsis or two hours after the initial antisepsis. This suggests there is no difference in the number of colony forming units on hands between a five minute initial scrub and a three minute initial scrub using chlorhexidine. No statistically significant differences were found in the number of colony forming units on participants' hands two hours after the subsequent antisepsis. There is no difference in the number of colony forming units on hands between a three and a half minute subsequent scrub and a two and a half minute subsequent scrub when using chlorhexidine.
Wheelock (1997) randomised twenty-five operating room nurses and surgical technologists to either a two minute or a three minute scrub. After carrying out the trial scrub the participant changed to the alternative intervention after leaving a gap of one week, though they continued to undertake scrubbing as part of their usual work. Though the intention of the trial authors was for participants to use aqueous 4% chlorhexidine gluconate (Hibiclens), participants with a history of skin irritation (15/25 participants) used either 2% chlorhexidine gluconate or parachlorometaxylenol (PCMX). Colony forming units were measured one hour after the surgical scrub. There was no difference in the number of colony forming units on hands between a two and a three minute scrub.
These four trials compare several antiseptics for varying durations and it is difficult to pool the findings together. However, overall it would appear that shorter scrubs of two and three minutes are as effective as longer five minute scrubs. As there appears to be no difference to bacteria on hands it is possible to state that a shorter two minute scrub will not increase surgical site infections.
Studies on surgical hand antisepsis are divided into two categories: those measuring colony forming units on hands and those measuring surgical site infections in patients. The problem with studies measuring colony forming units is that this is only a surrogate measurement, an indication of the real outcome measurement, and it is not always possible to draw conclusions from these studies. For example, if a study comparing two interventions shows no difference in the number of colony forming units on the hands of the surgical team then we can assume that the two interventions will show no difference in surgical site infections in patients. However, if two interventions show there is a difference in colony forming units it is not possible for us to say whether this difference will have any impact on surgical site infections. A good example of this is the evidence surrounding rubs versus scrubs. Most of the studies measuring colony forming units show that alcohol rubs are more effective than aqueous scrubs. However the one large trial measuring surgical site infections shows no difference. This suggests that a difference in colony forming units on hands does not equate to a difference in surgical site infections.
Most studies measure colony forming units rather than surgical site infections because these studies are easier to conduct and much cheaper. It is comparatively easy to recruit individuals to a study and test their hand bacterial counts before and after antisepsis. Conversely to measure surgical site infections, consent must be obtained from patients, the whole of the scrub team must take part as one unit and all perform the same scrub protocol, and the patient must be followed up for 30 days postoperatively to identify infections. While a sample size of around 100 staff is sufficient to measure colony forming units, the sample size of a study measuring surgical site infection should include several thousand patients.
Is surgical hand antisepsis necessary?
While we have explored several aspects of surgical hand antisepsis we have not yet challenged the most fundamental question: is there any evidence to support the surgical scrub? I referred earlier in this article to Caroline Hampton, the scrub nurse who washed her hands with carbolic acid and mercuric chloride. She became famous as the first person to wear surgical gloves. The gloves were designed by surgeon John Halstead, whom she later married, to protect her hands from eczema caused by the cleaning solutions. Once in receipt of surgical gloves Miss Hampton abandoned performing antiseptic scrubs--cleaning the gloves instead of her hands. We therefore must ask ourselves if sterile surgical gloves negate the need for surgical hand antisepsis. Has the advent of quality sterile surgical gloves superseded surgical hand antisepsis? It would appear that in the 150 year history of surgical hand antisepsis this fundamental question has not been raised.
There is one study, which appears to have a possible bearing on this question, and this study suggests that surgical hand antisepsis might not have any impact on surgical site infections. This is the study by Parienti et al (2002). When viewed in conjunction with Herruzo and Pietsch's study it may appear that there is no relationship between colony forming units on hands and surgical site infections in patients.
If antisepsis could be replaced by a simple hand wash then this would have considerable cost and resource implications for operating room departments. Personnel time would be reduced and equipment costs (brushes, sponges, antiseptic solution, sterile towels, scrub sinks) eliminated.
Conclusion and recommendations
Some of the evidence surrounding surgical hand antisepsis is limited as it measures colony forming units (number of bacteria) on the hands of the surgical team rather than surgical site infections in patients. The only study which measured surgical site infection found that alcohol rubs were equally effective as aqueous scrubs. The findings from other studies measuring colony forming units suggest that chlorhexidine gluconate is more effective than povidone iodine and a two minute scrub is as effective as a longer scrub.
Australian College of Operating Room Nurses 2004 ACORN Standards O'Halloran Hill, ACORN
Association for Perioperative Practice 2007 Standards and Recommendations for Safe Perioperative Practice 2007 Harrogate, AfPP
Association of periOperative Registered Nurses 2006 Standards, Recommended Practices and Guidelines Denver, Association of periOperative Registered Nurses
Furukawa K, Tajiri T, Sudzuki H, Norose Y 2005 Are sterile water and brushes necessary for hand washing before surgery in Japan? Journal of Nippon Medical School 72 (3) 149-154
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Kappstein I, Schulgen G, Waninger J, Dascher F 1993 Mikrobiologische und okonomische Untersuchungen uber verkurzte Verfahen fur die chirurgische Handedesinfektion [Microbiological and economic studies of abbreviated procedures for surgical hand disinfection] Der Chirurg 64 (5) 400-405
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Parienti JJ, Thibon P, Heller R, Le Roux Y, Theobald P, Bensadoun H, Bouvet A, Lemarchand F, Le Coutour X 2002 Hand-rubbing with an aqueous alcoholic solution versus traditional surgical hand-scrubbing and 30-day surgical site infection rates Journal of American Medical Association 288 (6) 722-727
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Pietsch H 2001 Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels Journal of Hospital Infection 48 (Supplement A) S33-S36
Sensoz O, Uysal AC, Baran CN 2003 Pre-surgical scrubbing in plastic and reconstructive surgery: a prospective study European Journal of Plastic Surgery 25 369-373
Springer R 2002 To brush or not to brush Plastic Surgical Nursing 22 (4) 185-188
Tanner J, Blunsden C, Fakis A 2007 National survey of hand antisepsis practices Journal of Perioperative Practice 17 (1) 27-37
Tanner J, Swarbrook S, Stuart J 2008 Surgical hand antisepsis to reduce surgical site infection The Cochrane Database of Systematic Reviews, Issue 1, Chichester, John Wiley and Sons Ltd
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Correspondence address: De Montfort University and University Hospitals Leicester, Charles Frears Campus, 266 London Road, Leicester, LE2 1RQ. Email: email@example.com or Judith.Tanner@uhl-tr.nhs.uk
BN, MPhil, PhD
Chair of Clinical Nursing Research, De Montfort University and University Hospitals Leicester
Table 1 Surgical hand antisepsis (AfPP 2007) * Hands are washed with plain soap or an anti-microbial solution and running water prior to commencing the first antisepsis of the day. * Hands and arms are wet before anti-microbial solutions are applied. * Nails should be cleaned using a nail pick under running water. * Scrubbing brushes are not necessary (not to be confused with nail brushes). * Two minute wash is sufficient as a longer wash does not provide additional benefits. * Alcohol rubs are an acceptable alternative to aqueous scrubs when performing repeated washes. * Anti-microbial solutions used should be fast acting, have a broad spectrum of activity and a residual effect.
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|Title Annotation:||CLINICAL FEATURE|
|Publication:||Journal of Perioperative Practice|
|Date:||Aug 1, 2008|
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