vivo comparative efficacy of three surgical hand preparation agents

Transcrição

Journal of Hospital Infection 86 (2014) 64e67
Available online at www.sciencedirect.com
Journal of Hospital Infection
journal homepage: www.elsevierhealth.com/journals/jhin
In vivo comparative efficacy of three surgical hand
preparation agents in reducing bacterial count
P. Barbadoro a, b, E. Martini a, S. Savini a, A. Marigliano b, E. Ponzio b,
E. Prospero a, b, *, M.M. D’Errico a, b
a
Hospital Hygiene Service, Ospedali Riuniti, Ancona, Italy
Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health,
Università Politecnica delle Marche, Ancona, Italy
b
A R T I C L E
I N F O
Article history:
Received 18 June 2013
Accepted 23 September 2013
Available online 16 October
2013
Keywords:
Alcohol-based hand rub
Antiseptics
Efficacy
Surgical hand hygiene
S U M M A R Y
Background: Besides objective efficacy, the choice between an antiseptic-based liquid
soap, or an alcohol-based hand rub for surgical hand preparation technique is based on
personal preference. Glycerol is often added to the formulations in order to enhance
tolerability; however, it has been recently reported as a factor reducing the sustained
effect of surgical hand rubs.
Aim: To compare the efficacies of three commercial products for hand decontamination.
Methods: The in vivo efficacy of an alcohol-based hand rub (isopropyl alcohol 40%; Npropyl alcohol 25%; glycerin 1.74%; triethanolamine salt of carbomer <1%) was compared
with other widely used products in surgical hand antisepsis (chlorhexidine and povidoneiodine). All products were used according to the manufacturers’ instructions.
Findings: The best results were achieved with the alcohol-based hand rub and these were
sustained for a period of 3 h. Some volunteers experienced skin peeling off the hands when
using alcohol-based hand rub; in this group of participants, the bacterial count was
reduced only by 0.91 ! 1.67 log10 compared with 2.86 ! 1.22 log10 in the group who did not
show this phenomenon.
Conclusion: Besides confirming the importance of alcohol-based hand rubs for surgical
hand decontamination, the results suggest the value of assessing the characteristics, and
response of healthcare workers’ skin, that may contribute to the development of skin
peeling, and the subsequent possibility of a paradoxical overcolonization of hands after
surgical preparation with alcohol-based hand rub.
ª 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Surgical site infections (SSIs) are still among the most
common hospital-acquired infections worldwide despite
* Corresponding author. Address: Dipartimento di Scienze Biomediche e Sanità Pubblica, Università Politecnica delle Marche, Via
Tronto 10/a, 60020 Torrette di Ancona, Italy. Tel.: þ39 0712206030;
fax: þ39 0712206032.
E-mail address: [email protected] (E. Prospero).
significant developments in surgical technique.1,2 Disinfection
can be performed using a surgical hand wash with an antiseptic
liquid soap, or with an alcohol-based hand rub.3,4 Products for
surgical hand disinfection should pass two European standards
for bactericidal efficacy: European Norm (EN) 12054, which is a
suspension test using four different test bacteria to determine
a general bactericidal activity; and EN 12791, which is a test
used to determine the bactericidal efficacy in vivo.5e7 However, recently there has been a growing interest in challenging
surgical handwashing procedure in real working settings, and
0195-6701/$ e see front matter ª 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jhin.2013.09.013
P. Barbadoro et al. / Journal of Hospital Infection 86 (2014) 64e67
the formulations recommended by the World Health Organization have been discussed.8e10 Moreover, the glycerol
component of alcohol-based hand rub has been recently evaluated as a factor reducing the sustained effect of surgical hand
rubs.11
The objective of this work was to compare the in vivo efficacy of an alcohol formulation with respect to other widely
used products in surgical hand antisepsis.
Methods
Products tested
The tested products were based on the following formulations: (i) chlorhexidine (chlorhexidine gluconate 4%; propan-2ol 1e5%; lauryldimethylamine oxide 1e5%; glycerol 1e5%); (ii)
povidone-iodine (7.5%); and (iii) an alcohol formulation (isopropyl alcohol 40%; N-propyl alcohol 25%; glycerin 1.74%;
triethanolamine salt of carbomer <1%). The following neutralizers were used: polysorbate 80 (3%), saponin (0.3%), histidine (0.1%) and cysteine (0.1%). The in vivo bactericidal
efficacy of the three products was assessed in 20 healthy volunteers aged 27e50 years. The skin of the volunteers was free
from cuts or abrasions and no other skin disorders were present. Nails were short and clean. In three distinct cross-over
experiments, each formulation containing one of the three
products was tested. A washout period of one week was
allowed between each test run. At the end of the four experiments, each volunteer had used each formulation once. Volunteers participated after having expressed a written informed
consent.
Wash phase (pre-values)
To remove transient bacterial flora and foreign agents,
volunteers’ hands were washed with a plain soap with the
following procedure: 10 mL of the soap was poured into the
cupped dry hands and rubbed vigorously on to the skin up to the
wrists in accordance with the standard procedure to ensure
total coverage of the hands, which were then rinsed in running
tap water and dried with a sterile paper towel.
For the determination of the pre-values of colony-forming
units (cfu), the distal phalanges of the right and left hand
were rubbed separately, including thumbs, for 1 min on to two
9 cm Petri dishes containing 10 mL tryptic soy broth (TSB). A
0.1 mL aliquot, as well as the same volume of 1:10 and 1:100
dilutions, were seeded in TSB. Sampling fluids were spread over
tryptic soy agar dishes with a sterile glass spatula. Two dishes
were used for each dilution. No more than 5 min elapsed between sampling and seeding. Dishes were incubated for 24 h at
37 ! 2 # C. After an initial count of the cfu, Petri dishes were
incubated for another 24 h to detect slow-growing colonies.5
Surgical preparation phase
Each volunteer used the test products at least on a weekly
basis, in order to allow reconstitution of participants’ skin
flora. All products were used according to the manufacturers’
instructions. After surgical hygiene, hands were rinsed with
running tap water for 15 s and dried with a sterile cotton towel.
65
Determination of post values
After hand preparation, one hand was randomly selected to
obtain the post-value (immediate effect). The other hand was
allowed to dry and thereafter gloved (sterile surgical glove) for
3 h for assessment of the sustained effect, obtained after
removal of the glove. In order to obtain the post-value, TSB
with neutralizers was used. The neutralizers were 3% Tween80, 3% saponin, 0.1% histidine and 0.1% cysteine. Sampling
was done in a similar way to the immediate effect.
Moreover, participants were asked to report eventual personal notation about the effects of the different products on
their skin (such as: dusty, sticky sensations).
Data analysis
For each dilution the mean number of cfu scored in duplicate
dishes was calculated. This was multiplied by the dilution factor
in order to obtain the number of cfu per millilitre of sampling
liquid. Pre- and post-values were expressed as log10 values. For
calculation purposes values of 0 were reset to 1, whereas values
uncountable in the Petri dish were considered as 1,000,000 cfu
(with log10 ¼ 6). If countable values of cfu were obtained from
more than one dilution their mean was used to calculate the
final logarithm value. For each volunteer the reduction factor
(RF) was obtained as the difference between log10 post-values
and the log10 pre-value. The mean of the log10 values (RF) of
each product were compared with the corresponding values for
a paired analysis of the immediate and sustained effect. Paired
t-test was used to compare immediate and sustained effect
globally for each product. Difference between mean RFs of
different products was performed with analysis of variance
(ANOVA) with Bonferroni correction for multiple comparisons; a
post-hoc analysis was performed with Tukey’s honestly significant difference (HSD) test. All analysis were two-tailed, with
level of significance set at P < 0.05. Analyses were performed by
using Stata 9.0 software (Stata Corp., College Station, TX, USA).
Results
Alcohol-based product had an immediate mean RF significantly higher than the other agents (Figure 1); in particular, the
alcohol formulation showed a mean 2.27 ! 1.64 log10 reduction, followed by chlorhexidine, with 0.94 ! 1.11 log10 reduction, and povidone-iodine 0.16 ! 0.42.
Comparison of mean RFs using an ANOVA model revealed a
significant difference between the products (F ¼ 17.03;
P < 0.0001). In order to clarify the results, we report pair-wise
comparisons between each couple of tested products (Table I).
The post-hoc analysis revealed that the alcohol-based product
was significantly more effective compared with the other
tested products (P < 0.0001; Tukey’s HSD). After 3 h (Figure 2)
the situation was similar to that registered immediately. In
particular, after 3 h the alcohol formulation showed a mean
1.91 ! 1.52 log10 reduction, followed by chlorhexidine, with
0.82 ! 1.16 log10 reduction, and povidone iodine 0.52 ! 0.92.
ANOVA tests showed a significant difference between sustained effects for all the products (F ¼ 7.12; P < 0.01); details
for pairwise comparisons of product are reported in Table II.
The post hoc analysis revealed that the alcohol-based product
was significantly more effective compared with the other
tested products (P < 0.0001; Tukey’s HSD).
66
-6
-6
-4
-4
Reduction factor
0
-2
Reduction factor
-2
0
2
2
Alcohol
Chlorhexidine
Povidone-iodine
Alcohol
Chlorhexidine
Povidone-iodine
Figure 1. Box plot showing immediate effect (reduction factor
with respect to plain soap) of different agents.
Figure 2. Box plot showing sustained effect (reduction factor
with respect to plain soap after 3 h) of different agents.
On the hands of 35% (7/20) of volunteers, small sticky agglomerates appeared, presumably formed by the reaction between flaking skin cells and the glycerol of the alcohol hand rub
while performing hand hygiene with alcohol-based hand rub.
We have defined this phenomenon as ‘skin peeling’. In participants experiencing this phenomenon, the RF for the sustained
effect was significantly lower than that registered for the immediate effect (1.06 ! 0.47 log10 vs 2.48 ! 1.24 log10 with
respect to the group who did not show this phenomenon,
P < 0.05). This difference was not significant in participants
who did not experience the skin peeling (with immediate RF of
2.16 ! 1.82 log10 vs 2.37 ! 1.71 log10 of RF for sustained effect,
P > 0.05).
Our main finding is that significant differences under practical conditions were observed in vivo for products currently
used in surgical hand preparation. The best results were achieved with the alcohol-based hand rub. This is not surprising as
their efficacy in the preoperative treatment of hands is well
known; nevertheless many professionals involved in surgical
procedures remain reluctant to switch from an antiseptic soap
to an alcohol-based hand rub.12 Moreover, Tanner et al. have
concluded that the quality of the sum of the evidence
regarding alcohol hand rub use for surgical hand preparation is
variable and that the effects on the outcome, when considering
surgical site infections, is mixed.1
The excellent immediate effect may also be enhanced by
the presence of excipients, that have been shown to be
important.9 However, we also note the paradoxical effect
shown in vivo in volunteers with self-reported skin peeling,
resulting in a higher number of cfu measured at 48 h compared
with volunteers without skin peeling. In our opinion, such hand
rubs may cause the formation of small agglomerates in selected
users which feel like ‘gritty’ particles on the hands (skin
peeling). This effect has already been described in association
with the use of powdered gloves, but in this trial this effect was
not related to use of powdered gloves, since it was noted after
hand disinfection and before glove use.3 This finding may suggest that the substantially reduced effect of alcohol-based
hand rub, in selected participants, may be associated with
the glycerol content of the gel, as has been recently reported,
and may also be responsible for the ‘gritty’ particles noted by
some participants.11 We agree with Suchomel et al., who
discuss the possible role of glycerol in producing a moister
environment under surgical gloves, thus supporting the multiplication of residual skin flora and drawing bacterial flora from
deeper skin layers. In accordance with the Guideline for Hand
Hygiene in Health-Care Settings, we may suggest switching to
an alternative product, or using hand washing after disinfection with alcohol products for these professionals.3,11 Further
studies are needed to investigate the interactions between skin
flora and the glycerol content of the alcohol hand rub. Moreover, we must underline that a modified version of the above
hand rub has been adopted in other countries, but is not
licensed in Italy, where only the above-tested product is
available.
In conclusion, our experience confirms the importance of
alcohol-based hand rubs for the surgical decontamination of
hands. Moreover, our results highlight the value of assessing the
characteristics, and response of healthcare workers’ skin, that
may contribute to the development of clumps which may
contribute to a paradoxical overcolonization 3 h after surgical
Table I
Difference between reduction factor, pairwise comparison of
product for immediate effect
Table II
Difference between reduction factor, pairwise comparison of
product for sustained effect
Discussion
Alcohol
Chlorhexidine
Povidone-iodine
a
1.33
2.11a
P < 0.05 (analysis of variance).
Chlorhexidine
a
0.78a
Alcohol
Chlorhexidine
Povidone-iodine
a
1.09
1.39a
P < 0.05 (analysis of variance).
Chlorhexidine
a
0.30a
hand decontamination with alcohol-based hand rubs containing
glycerol. These results underline the need to obtain a more
powerful, yet tolerable, hand solution in order to overcome
barriers to utilization, side-effects, and to improve hand hygiene behaviour.
Conflict of interest statement
None declared.
Funding sources
None.
References
1. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce
surgical site infection. Cochrane Database Syst Rev
2008;(1):CD004288.
2. Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare
Safety Network (NHSN) Report, data summary for 2010, deviceassociated module. Am J Infect Control 2011;39:798e816.
3. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory
Committee, et al. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand
Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23:S3eS40.
4. Pittet D, Allegranzi B, Boyce J, World Health Organization World
Alliance for Patient Safety First Global Patient Safety Challenge
Core Group of Experts. The World Health Organization Guidelines
on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611e622.
67
5. European Norm (EN) 12054. Chemical disinfectants and antiseptics. Quantitative suspension test for the evaluation of bactericidal activity of products for hygienic and surgical hand rub and
hand wash used in human medicine. Test method and requirements (Phase 2/Step 1). Brussels: Comitè Europeen de Normalisation; 2001.
6. European Norm (EN) 12791. Chemical disinfectants and antiseptics e surgical hand disinfection. Test method and requirements (Phase 2/Step 2). Brussels: Comitè Europeen de
Normalisation; 2005.
7. Labadie J-C, Kampf G, Lejeune B, et al. Recommendation for
surgical hand disinfection requirements, implementation and need
for research. A proposal by representatives of the SFHH, DGHM
and DGKH for a European discussion. J Hosp Infect 2002;51:
312e315.
8. Suchomel M, Kundi M, Allegranzi B, Pittet D, Rotter ML. Testing of
the World Health Organization-recommended formulations for
surgical hand preparation and proposals for increased efficacy.
J Hosp Infect 2011;79:115e118.
9. Edmonds SL, Macinga DR, Mays-Suko P, et al. Comparative efficacy
of commercially available alcohol-based hand rubs and World
Health Organization-recommended hand rubs: formulation matters. Am J Infect Control 2012;40:521e525.
10. Kampf G, Ostermeyer C. WHO-recommended hand-rub formulations do not meet European efficacy requirements for surgical
hand disinfection in 5 minutes. J Hosp Infect 2011;78:123e127.
11. Suchomel M, Rotter M, Weinlich M, Kundi M. Glycerol significantly
decreases the three hour efficacy of alcohol-based surgical hand
rubs. J Hosp Infect 2013;83:284e287.
12. Rotter ML. Arguments for alcoholic hand disinfection. J Hosp
Infect 2001;48(Suppl. A):S4eS8.
A systemAtic review of surgicAl hAnd Antisepsis utilizing An Alcohol
prepArAtion compAred to trAditionAl products
Artigo de revisão
Revisão sistemática sobre antissepsia cirúrgica
das mãos com preparação alcoólica em
comparação aos produtos tradicionais*
revisión sistemáticA sobre AntisepsiA quirúrgicA de mAnos con
prepArAción AlcohólicA compArAdA A productos trAdicionAles
Karen de Jesus Gonçalves1, Kazuko Uchikawa Graziano2, Julia Yaeko Kawagoe3
RESUmo
AbStRAct
RESUmEn
A antissepsia cirúrgica das mãos visa à
prevenção de infecções do sítio cirúrgico,
importante causa de morbimortalidade
pós-operatória e aumento dos custos hospitalares. Este estudo teve como objetivo
comparar a eficácia de preparações alcoólicas com os produtos tradicionais na antissepsia cirúrgica das mãos por meio de uma
revisão sistemática da literatura. Foram
considerados estudos primários ou secundários, tendo como desfecho a contagem
microbiana das mãos ou taxas de infecções
do sítio cirúrgico. A busca foi realizada no
Portal BVS, PubMed, Ask e MEDLINE. Foram selecionados 25 estudos (2 revisões
sistemáticas, 19 experimentais e 4 de coorte). As preparações alcoólicas tiveram
uma redução microbiana igual e/ou maior
aos produtos tradicionais em 17 estudos e
inferior em 4; as taxas de infecções do sítio
cirúrgico foram similares. Portanto, existem evidências científicas que suportam a
segurança das preparações alcoólicas para
antissepsia cirúrgica das mãos.
Surgical hand antisepsis aims at preventing
surgical site infections, an important cause
of postoperative morbidity and mortality
and escalating hospital costs. The objectives of this study were to compare the
efficacy of alcohol preparations with traditional surgical hand antisepsis products by
means of a systematic review of the literature. Primary and secondary studies were
included, considering the microbial count
or surgical site infection rates as outcomes.
The search was performed on the BVS Portal, PubMed, Ask and MEDLINE. Twentyfive studies were selected (two systematic
reviews, nineteen experimental and four
cohort studies). The alcohol preparations
promoted a microbial reduction equal to
and/or greater than traditional products
in 17 studies, and a lesser reduction in
four studies; similar surgical site infection
rates were identified. Therefore, there is
scientific evidence that support the safety
of alcohol preparations for surgical hand
antisepsis.
La antisepsia quirúrgica de manos apunta
a prevenir infecciones en el sitio quirúrgico, causa importante de morbi-mortalidad
postoperatoria y aumento de costos hospitalarios. El estudio objetivó comparar la
eficacia de preparaciones alcohólicas con
los productos tradicionales de la antisepsia quirúrgica de manos, mediante revisión
sistemática de la literatura. Fueron considerados estudios primarios o secundarios,
teniendo como objetivo el recuento microbiano en manos o tasas de infecciones del
sitio quirúrgico. La búsqueda fue realizada
en las bases BVS, PubMed, Ask y MEDLINE.
Fueron seleccionados 25 estudios (2 revisiones sistemáticas, 19 experimentales y 4
de cohorte). Las preparaciones alcohólicas
consiguieron una reducción microbiana
igual y/o mayor que los productos tradicionales en 17 estudios, e inferior en 4;
las tasas de infección del sitio quirúrgico
fueron equivalentes. Por lo tanto, existen
evidencias científicas que dan soporte a la
seguridad de las preparaciones alcohólicas
para la antisepsia quirúrgica de las manos.
dEScRitoRES
dEScRiPtoRS
dEScRiPtoRES
Antissepsia
Cirurgia geral
Lavagem de mãos
Controle de infecções
Enfermagem de Centro Cirúrgico
Antisepsis
General surgery
Handwashing
Infection control
Operating Room Nursing
Antisepsia
Cirugía general
Lavado de manos
Control de infecciones
Enfermería de quirófano
* extraído do trabalho de conclusão de curso “revisão sistemática sobre antissepsia cirúrgica das mãos com preparação alcoólica em comparação
aos produtos tradicionais”, escola de enfermagem da universidade de são paulo, 2010. 1 enfermeira pela escola de enfermagem da universidade de
são paulo. são paulo, sp, brasil. [email protected] 2 enfermeira. professora titular do departamento de enfermagem médico-cirúrgica da escola de
enfermagem da universidade de são paulo. são paulo, sp, brasil. [email protected] 3 enfermeira epidemiologista do serviço de controle de infecção do
hospital israelita Albert einstein. são paulo, sp, brasil. [email protected]
1484
Rev Esc Enferm USP
2012; 46(6):1484-93
www.ee.usp.br/reeusp/
recebido: 09/05/2011
Aprovado: 09/12/2011
das mãos
com
português
/ inglês
preparação alcoólica em comparação aoswww.scielo.br/reeusp
produtos tradicionais
Gonçalves KJ, Graziano KU, Kawagoe JY
A systemAtic review of surgicAl hAnd Antisepsis utilizing An Alcohol
prepArAtion compAred to trAditionAl products
Artigo de revisão
das mãos com preparação alcoólica em
comparação aos produtos tradicionais*
revisión sistemáticA sobre AntisepsiA quirúrgicA de mAnos con
prepArAción AlcohólicA compArAdA A productos trAdicionAles
Karen de Jesus Gonçalves1, Kazuko Uchikawa Graziano2, Julia Yaeko Kawagoe3
RESUmo
AbStRAct
RESUmEn
A antissepsia cirúrgica das mãos visa à
prevenção de infecções do sítio cirúrgico,
importante causa de morbimortalidade
pós-operatória e aumento dos custos hospitalares. Este estudo teve como objetivo
comparar a eficácia de preparações alcoólicas com os produtos tradicionais na antissepsia cirúrgica das mãos por meio de uma
revisão sistemática da literatura. Foram
considerados estudos primários ou secundários, tendo como desfecho a contagem
microbiana das mãos ou taxas de infecções
do sítio cirúrgico. A busca foi realizada no
Portal BVS, PubMed, Ask e MEDLINE. Foram selecionados 25 estudos (2 revisões
sistemáticas, 19 experimentais e 4 de coorte). As preparações alcoólicas tiveram
uma redução microbiana igual e/ou maior
aos produtos tradicionais em 17 estudos e
inferior em 4; as taxas de infecções do sítio
cirúrgico foram similares. Portanto, existem evidências científicas que suportam a
segurança das preparações alcoólicas para
antissepsia cirúrgica das mãos.
Surgical hand antisepsis aims at preventing
surgical site infections, an important cause
of postoperative morbidity and mortality
and escalating hospital costs. The objectives of this study were to compare the
efficacy of alcohol preparations with traditional surgical hand antisepsis products by
means of a systematic review of the literature. Primary and secondary studies were
included, considering the microbial count
or surgical site infection rates as outcomes.
The search was performed on the BVS Portal, PubMed, Ask and MEDLINE. Twentyfive studies were selected (two systematic
reviews, nineteen experimental and four
cohort studies). The alcohol preparations
promoted a microbial reduction equal to
and/or greater than traditional products
in 17 studies, and a lesser reduction in
four studies; similar surgical site infection
rates were identified. Therefore, there is
scientific evidence that support the safety
of alcohol preparations for surgical hand
antisepsis.
La antisepsia quirúrgica de manos apunta
a prevenir infecciones en el sitio quirúrgico, causa importante de morbi-mortalidad
postoperatoria y aumento de costos hospitalarios. El estudio objetivó comparar la
eficacia de preparaciones alcohólicas con
los productos tradicionales de la antisepsia quirúrgica de manos, mediante revisión
sistemática de la literatura. Fueron considerados estudios primarios o secundarios,
teniendo como objetivo el recuento microbiano en manos o tasas de infecciones del
sitio quirúrgico. La búsqueda fue realizada
en las bases BVS, PubMed, Ask y MEDLINE.
Fueron seleccionados 25 estudios (2 revisiones sistemáticas, 19 experimentales y 4
de cohorte). Las preparaciones alcohólicas
consiguieron una reducción microbiana
igual y/o mayor que los productos tradicionales en 17 estudios, e inferior en 4;
las tasas de infección del sitio quirúrgico
fueron equivalentes. Por lo tanto, existen
evidencias científicas que dan soporte a la
seguridad de las preparaciones alcohólicas
para la antisepsia quirúrgica de las manos.
dEScRitoRES
dEScRiPtoRS
dEScRiPtoRES
Antissepsia
Cirurgia geral
Lavagem de mãos
Controle de infecções
Enfermagem de Centro Cirúrgico
Antisepsis
General surgery
Handwashing
Infection control
Operating Room Nursing
Antisepsia
Cirugía general
Lavado de manos
Control de infecciones
Enfermería de quirófano
* extraído do trabalho de conclusão de curso “revisão sistemática sobre antissepsia cirúrgica das mãos com preparação alcoólica em comparação
aos produtos tradicionais”, escola de enfermagem da universidade de são paulo, 2010. 1 enfermeira pela escola de enfermagem da universidade de
são paulo. são paulo, sp, brasil. [email protected] 2 enfermeira. professora titular do departamento de enfermagem médico-cirúrgica da escola de
enfermagem da universidade de são paulo. são paulo, sp, brasil. [email protected] 3 enfermeira epidemiologista do serviço de controle de infecção do
hospital israelita Albert einstein. são paulo, sp, brasil. [email protected]
1484
Rev Esc Enferm USP
2012; 46(6):1484-93
recebido: 09/05/2011
Aprovado: 09/12/2011
das mãos
com
português
/ inglês
preparação alcoólica em comparação aoswww.scielo.br/reeusp
produtos tradicionais
intRodUção
As infecções do sítio cirúrgico (ISC) são a maior causa de
morbi-mortalidade pós-operatória e representam grandes
gastos para os hospitais(1). Apesar da causa multifatorial,
estudos têm correlacionado as ISC, por meio de biologia
molecular, às falhas na antissepsia cirúrgica das mãos da
equipe cirúrgica, causando inclusive surtos(2-4).
A paramentação cirúrgica, medida bem estabelecida
para prevenção das infecções do sítio cirúrgico, consiste
em antissepsia cirúrgica das mãos, utilização de aventais
e luvas esterilizadas, além de gorro e máscara(5). Apesar
do uso de luvas cirúrgicas, a transmissão de micro-organismos das mãos da equipe cirúrgica para o paciente pode ocorrer, considerando que ao final da cirurgia cerca de
18% (5 a 82%) das luvas cirúrgicas apresentam micro-perfurações, sendo que em mais de 80% dos casos essas perfurações não são percebidas pelos cirurgiões(6), e podem
dobrar o risco de infecções do sítio cirúrgico(7), tornando
esse preparo prévio das mãos essencial.
dade antimicrobiana (valor basal), imediatamente após a
antissepsia (efeito imediato) e após 3hs com mãos enluvadas (efeito residual). As amostras são colhidas por fricção
das pontas dos dedos em placas com meio de cultura e
neutralizantes, uma para cada mão. Os valores são expressos em unidades formadoras de colônias (UFC)/mL e
transformados em logaritmos decimais e não podem ser
significativamente inferiores aos obtidos com o produto
referência (PR). Para o produto ser classificado com efeito residual, os resultados obtidos após 3 horas devem ser
significativamente maiores que os obtidos pelo produto
referência. Também existem, na Europa, outras normas
para determinação do espectro antimicrobiano dos antissépticos em testes in-vitro, que precedem os in-vivo.
Nos Estados Unidos, vigora o método da American Society for Testing and Methods (ASTM E1115)(17), com testes in-vitro que medem o espectro antimicrobiano contra
uma quantidade específica de diferentes micro-organismos
e testes in-vivo. Nos testes in-vivo os produtos são utilizados por 5 dias consecutivos, sendo aplicados uma vez nos
dias 1º e 5º, e 3 vezes nos dias 2º, 3º e 4º.
O antisséptico cirúrgico deve ser capaz
O número de participantes é definido a partir
de eliminar totalmente a microbiota transio diferencial do álcool de uma fórmula, e antes do início do estudo
tória das mãos e reduzir significativamente
são colhidas amostras dos valores basais. As
a residente no começo do procedimento, e em relação aos outros amostras microbianas são colhidas imediataantissépticos é sua mente após a antissepsia (efeito imediato) e
inibir o seu crescimento em mãos enluvadas
rápida velocidade
até o final da cirurgia(8-13). Os antissépticos
após 3 e 6 horas com mãos enluvadas (efeito
mais utilizados atualmente são a clorexidide ação, além de
residual), nos dias 1º, 2º e 5º (efeito cumuna (CHG) e o polivinilpirrolidona iodo (PVPI)
excelente atividade lativo). Utiliza-se o método glove juice para
aplicados com esponja e/ou escova, apesar antimicrobiana contra coleta das amostras onde as mãos são aleada Organização Mundial da Saúde (OMS)
toriamente divididas nos tempos 1 minuto, 3
bactérias gramnão recomendar o uso de escovas para essa
horas e 6 horas após a aplicação. Os valores
positivas, gramfinalidade pelo seu efeito abrasivo(14).
obtidos expressos em UFC/mão são transfornegativas, fungos,
mados em log10. O produto testado deve atinAs preparações alcoólicas (PA) têm sido micobactérias e vírus.
gir os seguintes resultados: no dia 1º deve
(14)
recomendadas pela OMS , nas concentrahaver uma redução bacteriana de 1 log após
ções entre 60 e 80%, e pelo Centers for Disea1 minuto de aplicação, e após 6 horas não dese Control and Prevention (CDC) dos Estados
ve
exceder
o
valor
basal; ao final do dia 2º deve haver uma
Unidos(13), nas concentrações entre 60 e 95%, como produredução de 2 log após 1 minuto de aplicação; e ao final do
to de escolha na higienização das mãos e como alternativa
dia 5º uma redução de 3 log após 1 minuto de aplicação.
aos produtos tradicionais (PT) para antissepsia cirúrgica das
mãos, justificada pela eficácia antimicrobiana, facilidade de
Apesar desses movimentos na Europa e nos Estados
aplicação, menor dano à pele e economia de tempo(13-14). O Unidos e das recomendações da OMS e do CDC, o uso do
diferencial do álcool em relação aos outros antissépticos é álcool para antissepsia cirúrgica das mãos no Brasil, até
sua rápida velocidade de ação, além de excelente ativida- hoje não é uma prática difundida. Muitos acreditam que
de antimicrobiana contra bactérias Gram-positivas, Gram- a escovação vigorosa das mãos e antebraços é essencial
-negativas, fungos, micobactérias e vírus(8,13).
para o preparo da pele(15), além do método tradicional ser
considerado um ritual preparatório para a cirurgia(18) e um
Há cerca de 30 anos as preparações alcoólicas (PA) são momento de concentração da equipe cirúrgica. A prática
usadas na Europa para antissepsia cirúrgica das mãos(15). baseada em evidências (PBE) pode ser um dos passos paNos países deste continente, vigora a EN 12791 da Comi- ra vencer essa resistência ao uso do álcool, desde que se
té Européen de Normalisation (CEN)(16) como método de prove a eficácia desses produtos.
avaliação da eficácia de antissépticos destinados à antissepsia cirúrgica das mãos. Nele, a eficácia antimicrobiana
Esse estudo teve como questão norteadora: É segura a
dos produtos é testada em 20 voluntários sadios e adota- substituição da técnica tradicional de antissepsia cirúrgica
-se como produto referência (PR) o n-propanol 60% v/v, das mãos e antebraços da equipe cirúrgica por aplicação
aplicado por 3 minutos. As amostras microbianas são de preparações à base de álcool? e tem como relevância
colhidas após lavagem das mãos com sabonete sem ativi- subsidiar mudanças dessa prática no cenário nacional.
Revisão sistemática sobre antissepsia cirúrgica das mãos com
preparação alcoólica em comparação aos produtos tradicionais
Rev Esc Enferm USP
2012; 46(6):1484-93
1485
obJEtiVo
Comparar a eficácia antimicrobiana de preparações
alcoólicas com os produtos tradicionais na antissepsia cirúrgica das mãos, evidenciada pela literatura científica por
meio de uma revisão sistemática.
mÉtodo
A PBE, definida pelo Evidence Based Medicine Work
Group (Canadá) como o processo de sistematicamente
descobrir, avaliar e usar achados de investigações como
base para decisões clínicas(19), tem a revisão sistemática
como um recurso importante, na qual as informações relacionadas a um determinado problema são coletadas, categorizadas, avaliadas e sintetizadas(20).
O presente estudo trata-se de uma revisão sistemática da
literatura tendo como base as pesquisas básicas e revisões
sistemáticas, de modo a responder à pergunta da pesquisa.
A busca dos dados ocorreu entre os meses de junho e
setembro de 2010. Os estudos foram obtidos a partir de
acessos de domínio público: Portal BVS (Centro Latino-Americano e do Caribe de Informação em Ciências da
Saúde, também conhecido pelo seu nome original Biblioteca Regional de Medicina), que inclui busca nas bases e
portais LILACS (Literatura Latino-Americana e do Caribe
em Ciências da Saúde), IBECS (Índice Bibliográfico Español
en Ciencias de la Salud), MEDLINE (National Library of Medicine/NLM), The Cochrane Library e SciELO (Scientific Eletronic Library Online); PubMed (National Library of Medicine/NLM); e Ask MEDLINE. Também foi realizada busca
de referências cruzadas das publicações obtidas a partir
das bases de dados com o objetivo de encontrar outros
estudos não localizados com a busca eletrônica.
Os descritores da saúde utilizados na busca, com auxílio
de conectores booleanos, foram: antissepsia or lavagem de
mãos and salas cirúrgicas or centros de cirurgia or cirurgia
and etanol or 1-propanol or 2-propanol or feniletil álcool
and povidona-iodo or clorexidina. A busca em bases de língua inglesa foi realizada com os seguintes Medical Subject
Heading (MeSH) termos: surgical hand disinfection OR surgical hand antisepsis OR surgical hand rub OR surgical hand
rubbing OR surgical hand scrub OR surgical hand scrubbing
AND alcohol hand rubs OR alcohol-based hand rub OR alcohol OR n-propanol OR 1-propanol OR 2-propanol OR
isopropanol OR ethanol AND chlorhexidine OR povidone
iodine. No Ask Medline foi formulada a seguinte questão:
Could alcohol replace traditional surgical hand antisepsis?
Os critérios de inclusão dos estudos foram: estudos
primários ou secundários, que abordaram a eficácia da
antissepsia cirúrgica das mãos com preparações alcoólicas
em comparação aos produtos e técnicas tradicionais com
CHG ou PVPI; em campo ou em laboratório; com voluntários ou profissionais da saúde; apresentando como desfecho a redução da contagem microbiana das mãos ou taxas
1486
Rev Esc Enferm USP
2012; 46(6):1484-93
de infecções do sítio cirúrgico; nos idiomas inglês, português ou espanhol; sem restrição à data de publicação.
Os critérios de exclusão foram: artigos de reflexão, revisões de literatura narrativa; higienização simples das mãos
com álcool; artigos que não compararam a eficácia das preparações alcoólicas com produtos tradicionais; artigos que
utilizaram produtos tradicionais anteriormente à aplicação
da preparação à base de álcool; artigos em que o álcool não
era o principal ingrediente ativo da preparação alcoólica.
Os estudos foram analisados por três pesquisadores,
sendo dois deles especialistas no assunto e nos métodos
de investigação. A análise e seleção dos estudos foram realizadas em três fases. Na primeira, realizada por um único
investigador, os estudos foram analisados e pré-selecionados segundo os critérios de inclusão e exclusão por meio
de seus resumos, e quando estes não estavam disponíveis,
através do artigo completo. Após essa pré-seleção, os estudos foram analisados com instrumento de coleta de dados
baseado no modelo de Mendonça(21), incluindo: tipo de investigação, objetivos, amostra, método, desfechos, resultados e conclusão. A terceira fase incluiu a avaliação dos estudos pelos três investigadores de forma independente, com
ampliação da coleta de dados, com maior especificação em
relação aos objetivos dessa revisão sistemática, chegando
aos estudos selecionados para a pesquisa. Foram realizadas
reuniões para discussão e consenso entre os pesquisadores
acerca dos estudos, e sua inclusão ou exclusão.
Os estudos foram classificados quanto sua validade interna e nível de evidência seguindo o modelo proposto pela U.S. Preventive Services Task Force (USPSTF/Task Force)
(22)
, em cinco níveis de evidência: I – pelo menos um estudo
clínico controlado randomizado bem conduzido; II-1 – estudos clínicos controlados sem randomização bem conduzidos; II-2 – estudos de coorte ou caso-controle bem conduzidos; II-3 – múltiplos estudos longitudinais com ou sem
intervenção; e III – opiniões de autoridades respeitadas, baseadas na experiência clínica, estudos descritivos e relatos
de caso, ou relatos de comitês de especialistas. Cada nível
é subdividido em três categorias, bom, moderado e ruim,
de acordo com critérios de validade interna definidos para
cada tipo de estudo, incluindo revisões sistemáticas.
RESULtAdoS E diScUSSão
Por meio da busca eletrônica realizada foram localizados 132 artigos e com a análise de suas referências
obteve-se mais 25, totalizando 157 artigos. Desse total,
26 estudos foram excluídos por repetição e 79 por não
atenderem aos critérios de inclusão dessa pesquisa, sendo pré-selecionados 52 artigos. Não entraram na pesquisa
17 artigos que não foram obtidos textos completos. Após
análise dos textos na íntegra e reuniões de consenso, 10
artigos foram excluídos por não atenderem aos critérios
da pesquisa. Com isso, 25 estudos foram selecionados,
identificados por ordem cronológica como E1 a E23, R1 e
R2, estes últimos referentes a duas revisões sistemáticas.
O Quadro 1 apresenta os estudos selecionados com
seus respectivos autores, país de origem, ano de publicação, título e fonte de publicação. No Quadro 2 há um
resumo dos artigos em relação ao tipo de investigação,
nível de evidência, método utilizado, técnica de obtenção
da amostra microbiana, tempo de obtenção da amostra,
preparações alcoólicas e produtos tradicionais utilizados e
os principais resultados.
Quadro 1 - Estudos selecionados sobre antissepsia cirúrgica das mãos com antisséptico à base de álcool em substituição aos produtos tradicionais.
Estudo
Autor(es)
País
Ano
Fonte de
Publicação
Título
E1
Lowbury EJ, Lilly HA.
Reino Unido
1960
Disinfection of the hands of surgeons and nurses
Br Med J
E2
Lowbury EJ, Lilly HA, Bull JP.
Reino Unido
1964
Methods for disinfection of hands and operation sites
Br Med J
E3
Lowburry EJL, Lilly HA, Ayliffe
GAJ.
Reino Unido
1974
Preoperative disinfection of surgeons’ hands: use of
alcoholic solutions and effects of gloves on skin flora
Br Med J
E4
Jarvis JD, Wynne CD, Enwright
L, Williams JD.
Reino Unido
1979
Handwashing and antiseptic-containing soaps in hospital
E5
Larson EL, Butz AM, Gullette
DL, Laughon BA.
Estados Unidos
1990
Alcohol for surgical scrubbing?
Infect Control Hosp
Epidemiol
E6
Hobson DW, Woller W,
Anderson L, Guthery E.
Estados Unidos
1998
Development and evaluation of new alcohol-based
surgical and scrub formulation with persistent
antimicrobial characteristics and brushless application
Am J Infect Control
E7
Pietsch H.
Alemanha
2001
Hand antiseptics: rubs versus scrubs, alcoholic solutions
versus alcoholic gels
E8
Mulberry G, Snyder AT,
Heilman J, Pyrek J, Stahl J.
Estados Unidos
2001
Evaluation of a waterless, scrubless chlorexidine
gluconate/ethanol surgical scrub for antimicrobial
efficacy
Am J Infect Control
E9
Larson, Aiello, Heilman, Lyle,
Cronquist, Stahl, Della-Latta.
Estados Unidos
2001
Comparison of different regimens for surgical hand
preparation
AORN
E10
Bryce EA, Spence D, Roberts
FJ.
Canadá
2001
An in-use evaluation of an alcohol-based pre-surgical
hand disinfectant
Infect Control Hosp
Epidemiol
E11
Sigler M, Bastyr J, Stahl J,
Pyrek J.
Estados Unidos
2001
Comparison of a waterless, scrubless CHG/ethanol
surgical scrub to traditional CHG and povidone-iodine
surgical scrubs
3M Health Care.
E12
Parienti JJ; Thibon P; Heller
R; Le Roux Y; von Theobald
P; Bensadoun H; Bouvet A;
Lemarchand F; Le Coutour X.
França
2002
Hand-rubbing with an aqueous alcoholic solution vs
traditional surgical hand-scrubbing and 30-day surgical
site infections rates – a randomized equivalence study
JAMA
E13
Marchetti MG, Kampf G, Finzi
G, Salvatorelli G.
Itália, Alemanha
2003
Evaluation of the bactericidal effect of five products for
surgical hand disinfection according to prEN 12054 and
prEN 12791
J Hosp Infect
E14
Berman M.
Estados Unidos
2004
One hospital’s clinical evaluation of brushless scrubbing.
AORN J
E15
Rotter M, Kundi M, Suchomel
M, Harke H-P, Kramer A,
Ostermeyer C, Rudolph P,
Sonntag H-G, Werner H-P.
Alemanha, Áustria
2006
Reproducibility and workability of the European Test
Standard EN 12791 regarding the effectiveness of surgical
hand antiseptics: a randomized, multicenter trial
Infect Control Hosp
Epidemiol
E16
Hajipour L, Longstaff L, Cleeve
V, Brewster N, Bint D, Henman P.
Reino Unido
2006
Hand washing rituals in trauma theatre: clean or dirty?
Ann R Coll Surg
Engl
E17
Palmer JS.
Estados Unidos
2006
Use of Avagard in pediatric urologic procedures
Estados Unidos
2007
Comparison of two alcohol-based surgical scrub solutions
with an iodine-based scrub brush for presurgical antiseptic
effectiveness in a community hospital
J Hosp Infect
França
2007
An in-use microbiological comparison of two surgical
hand disinfection techniques in cardiothoracic surgery:
hand rubbing versus hand scrubbing
J Hosp Infect
Estados Unidos
2007
Influence of rings on the efficacy of hand sanitization and
residual bacterial contamination
J Clin Pathol
J Hosp Infect
Urology
E18
Gupta C; Czubatyj AM; Briski
LE; Malani AK.
E19
Carro C, Camilleri L, Traore
O, Badrikian L, Legaula B,
Azarnoush K, Dualé C, De
Riberolles C.
E20
Wongworawat MD, Jones SG.
E21
Marchand R, Theoret S, Dion D,
Pellerin M.
Canadá
2008
Clinical implementation of a scrubless chlorhexidine/
ethanol pre-operative surgical hand rub
E22
Kac G, Masmejean E, Gueneret M,
Rodi A, Peyrard S, Podglajen I.
França
2009
Bactericidal efficacy of a 1.5 min surgical hand-rubbing
protocol under in-use conditions
E23
Weight CJ; Lee MC; Palmer JS.
Estados Unidos
2010
Avagard hand antisepsis vs. Traditional scrub in 3600
pediatric urologic procedures.
Urology
Taiwan
2006
Surgical hand scrubs in relation to microbial counts:
systematic literature review.
J Adv Nurs
Reino Unido
2008
Surgical hand antisepsis to reduce surgical site infection.
R1
Hsieh HF, Chiu HH, Lee FP.
R2
Tanner J, Swarbrook S, Stuart J.
Infect Control Hosp
Epidemiol
Can Oper Room
Nurs J
J Hosp Infect
Cochrane Database
Syst Rev
Rev Esc Enferm USP
2012; 46(6):1484-93
1487
1488
Rev Esc Enferm USP
2012; 46(6):1484-93
Nível I Moderado
EClRL
Nível II-1 –
Ruim
EClL
A: Nível II-1 –
Moderado
B: Nível II-1 –
Ruim
C: Nível II-1 –
Ruim
EClL
A: Nível I –
Moderado
B: Nível II-1 –
Ruim
EClRL
A: Nível II-1 –
Moderado
B: Nível II-1 –
Ruim
60 pessoas (12
por grupo)
6 pessoas
A: 6 pessoas
B: não cita
C: não cita
A: 6 pessoas
B: 8 pessoas
para CHG ou
álcool+CHG e 2
para laurolínio
5 pessoas (A) e
20 luvas (B)
Amostra/
Perdas ou
Exclusões
Lavagem das
mãos com
solução Ringer
Técnica de
obtenção
da amostra
microbiana
Fricção da
ponta dos
dedos com
mão enluvada
[previamente
perfurada
nas pontas]
após lavagem
com sabonete
comum (A) e
caldo da luva
utilizada (B)
Outro
Outro
Glove juice
Antes, imediatamente e 4hs Álcool etílico 70% +
após a antissepsia CHG 0,5% 6x5mL.
nos dias 1º e 5º.
Antes,
imediatamente Álcool 95% + CHG
Lavagem das
após e após 90 0,5% por 2 min
mãos com
após 1ª e 6ª
solução Ringer min
antissepsia (3x/ (2x10mL).
dia por 2 dias).
Álcool 95% + CHG 0,5% > PVPI alcoólico > PVPI
> CHG > sabonete com PVPI > sabonete simples em
barra
Obs.: resultado com base nos valores absolutos.
A: álcool etílico 70% + CHG 0,5% = acetato de laurolínio
5% + álcool etílico 70% = acetato de laurolínio 5%
aquoso > PVPI = laurolínio spray > controle.
B: CHG 0,5% + álcool 70% = CHG 0,5% em todos os
tempos de aplicação.
Soluções de CHG > laurolínio com 30 e 120 min de
aplicação.
continua...
Triclosan 1%, CHG 4%, Betadine®2,
Álcool etílico 70% + CHG 0,5% > Betadine®2 >
sabonete sem atividade antimicrobiana, CHG 4% > triclosan 1% = sabonete sem atividade
todos por 2x5mL (5 min).
antimicrobiana
PVPI, CHG e PVPI alcoólico por 2
min (2x10mL), sabonete simples em
barra e sabonete em barra com PVPI
por 2 min
A: álcool etílico 95% + CHG 0,5% = álcool etílico
95,3% + tetrabromo metil fenol 0,1% > álcool etílico
95% = CHG 4% > CHG 0,5% > controle
Álcool etílico 95% + CHG 0,5% > CHG 4%
A: CHG 0,5% aquoso, CHG 4%;
Álcool etílico 95,3% + tetrabromo metil fenol 0,1%
ambos por 2 min (2x5mL), sabonete = CHG 4%
em barra e água por 2 min.
B: álcool isopropílico 70% + CHG 0,5% > CHG
4% > álcool isopropílico 70% > álcool etílico 70%
B: CHG 0,5% aquoso, PVPI
+ CHG 0,5% > álcool etílico 70% > PVPI > CHG
(Disadine®), clorexilenol 2,5% aquoso, 0,5% > cloroxilenol 2,5% > sabonete sem atividade
CHG 4% detergente, sabonete em
antimicrobiana.
barra sem atividade antimicrobiana;
CHG 4% com melhor efeito residual, álcool etílico
todos por 2 min.
70%, álcool isopropílico 70% e PVPI com os menores
efeitos residuais.
C: Irgasan 2% DP 300® detergente,
C: álcool etílico 95% + CHG 0,5% > álcool etílico 95,3%
sabonete.
+ tetrabromo metil fenol 0,1% > Irgasan DP 300 2% >
sabonete em barra.
Álcool etílico 70% sem efeito residual.
A: álcool etílico
95% + CHG 0,5%,
álcool etílico 95,3% +
tetrabromo metil fenol
0,1%, álcool etílico
95%; todos por 2 min
(2x5mL).
B: álcool etílico 70%
+ CHG 0,5%, álcool
isopropílico70% +
CHG 0,5%, álcool
isopropílico 70%,
álcool etílico 70%;
todos por 2 min.
C: álcool etílico
95% + CHG 0,5%,
álcool etílico 95,3% +
tetrabromo metil fenol
0,1%, álcool etílico
70%.
Antes e após
antissepsia
A: PVPI, acetato de laurolinio 5%
aquoso, laurolínio 5% spray por 2 min.
Controle: lavagem rápida sobre água.
B: CHG 0,5% aquoso, laurolínio 5%
aquoso por por 30, 60, 90 e 120 seg.
Neomicina e bacitracina > Phisohex® > álcool 70% +
CHG 0,5% > álcool 70% > hexaclorofeno 2% > swab
com álcool > sabonete
Resultados
A: álcool etílico 70% +
CHG 0,5%, acetato de
laurolinio 5% + álcool
etílico 70% por 2 min
B: álcool 70% + CHG
0,5%, laurolínio 5% +
álcool 70% por 30, 60,
90 e 120 seg.
Produto tradicional
Lavagem simples (rápida) com água e
sabonete (A). Sabonete em barra por 5
min. Sabonete em barra por 5 min seguido
de uso de luvas com pó de 5mg de sulfato
de neomicina e 5mg de bacitracina
por grama de pó (A). Hexaclorofeno
sabonete em todas as higienizações das
mãos e banhos durante a semana antes
do experimento, e por 5 min para o
experimento (A). Phisohex® em todas as
higienizações das mãos e banhos durante a
semana antes do experimento, e por 2 min
para o experimento (A).
Produto a base de
álcool
Sabonete em barra
por 5 min seguido da
aplicação de álcool 70%
por volume por 3 min
Sabonete em barra
Após 1 e 3h com (A).
5 min seguido da
mãos enluvadas por
de álcool 70%
(A) e ao final da aplicação
contendo CHG 0,5% por
cirurgia (B)
3 min (A). Sabonete em
barra por 5 min, seguido
de uma rápida fricção
com swab molhado com
álcool (A e B).
Tempo de
obtenção da
amostra
A: antes,
imediatamente
após antissepsia
a 1ª e 6ª
aplicação
(3x/dia
A: Outro
por 2 dias).
B: Outro (uso
Lavagem das
B: antes,
de luvas)
mãos com
imediatamente
C: Outro (efeito solução Ringer após
e após 3hs
residual)
da antissepsia
C: 3h após
antissepsia (com
contaminação
prévia)
Outro
Outro [avalia
microorganismos
que saem por
perfurações nas
luvas (A) e os
deixados no
interior da luva
após uso (B).
Método
e=estudo; revs= revisão sistemática; cl=clínico; co= coorte; r=randomizado; ce= cego; pce=parcialmente cego; re = retrospectivo; cc=no ambiente da unidade do centro cirúrgico;
cA=no ambiente de cirurgias Ambulatoriais; l=laboratorial.
*
E5
E4
E3
E2
E1
EClL (A) e CC
(B)
Tipo de InvestiEstudo gação*/Nível de
Evidência
Quadro 2 - Métodos e resultados da eficácia antimicrobiana de antissépticos para antissepsia cirúrgica das mãos a base de álcool e tradicionais.
Rev Esc Enferm USP
2012; 46(6):1484-93
1489
Outro
ASTM
prEN12054 e
prEN12791
Outro
27 pessoas
da equipe
cirúrgica/2
25 pessoas da
equipe cirúrgica
(em cirurgias
<2h) e 16 (em
cirurgias >3h)
124 pessoas (41
no grupo do
Hibiclens® e PA
e 42 no grupo do
Betadine®2)
4823 pacientes/
436
20 pessoas para
prEN 12791
75 pacientes
e todos os
membros da
equipe cirúrgica
que quiseram
participar/ vários
pacientes, 4
profissionais
EClRCC
Nível I Moderado
EClCC
Nível II-1 –
Moderado
EClRpCeL
Nível I Moderado
EClRCC
Nível I – Bom
EClRL
Nível I –
Moderado
ECoReCC
Nível II-2 –
Ruim
E9
E10
E11
E12
E13
E14
Outro
ASTM
Taxa de
infecção do
sítio cirúrgico
Fricção das
pontas dos
dedos
Taxa de
infecção do sítio
cirúrgico
Glove juice
Sterillium® 2x5mL
(total de 5 min).
-
Álcool etílico 70% +
piritionato de zinco
3 min.
Sterillium®, Softa
Man®, n-propanol
Antes, 1min e 3h 60% por 5 min no
após.
teste in-vitro e 3 min
(3mL quantas vezes
necessário) no in-vivo.
(em 30 dias)
Antes, 1 min, 3h Álcool etílico 61% +
e 6h após nos
dias 1º, 2º e 5º. CHG 1% 2x3mL.
Não cita.
®
Derman Plus , Hibiscrub , Betadine
por 5 min no teste in-vitro e 3 min
(3mL) no in-vivo.
®
Betadine®1 ou Hibiscrub® por 5 min.
Hibiclens® por 6 min (2x5mL),
Betadine®2 por 10 min (2x5mL).
CHG 4% ou PVPI 7,5% por 3 min.
CHG 4% por 6 min.
Antes e
imediatamente
após nos dias 1º
e 5º da primeira
semana e no
último dia da 3º
semana.
CHG 1% 3x2mL.
Hibiclens® 2x5mL (2x3 min).
Antes, 1 min, 3h Avagard® 3x2mL,
e 6h após nos álcool etílico 61%
dias 1º, 2º e 5º. 3x2mL.
®2
Hibiscrub® (não cita tempo).
Sterillium® (não cita
tempo).
Antes, imediatamente após
e ao final da
cirurgia.
Produto tradicional
Betadine®2 por 10 min ou Hibiclens®
por 6 min.
Produto a base de
álcool
Antes, 1 min, 3h
e 6h após nos Triseptin® por 3 min.
dias 1º, 2º e 5º.
Tempo de
obtenção da
amostra
Fricção das
Antes,
pontas dos
imediatamente Manorapid® por 3 min
dedos e glove após e ao final da (3x5mL).
juice
cirurgia.
Glove juice
Glove juice
Glove juice
Glove juice
Técnica de
obtenção
da amostra
microbiana
continua...
Álcool etílico 70% + piritionato de zinco = produto
tradicional
prEn12054: Sterillium®, Softa Man®, Derman Plus®,
Hibiscrub®, Betadine® = atendem aos critérios
prEN12791:
n-propanol 60% = Hibiscrub® e Softa Man®
n-propanol 60% > Betadine® e Derman Plus®
Sterillium® > n-propanol 60%
Sterillium® = Betadine® ou Hibiscrub®
Álcool etílico 61% + CHG 1% > Hibiclens® e
Betadine®2
Efeito cumulativo álcool etílico 61% + CHG 1% >
Betadine®2 e = Hibiclens®
Obs.: Betadine só atingiu os critérios ASTM após 1
min no dia 1º, Hibiclens atendeu somente nos dias 1º
e 5º, álcool etílico 61% + CHG 1% atendeu todos os
critérios
Cirurgias < 2h: Manorapid® = PVPI 7,5% ou CHG
4%
Cirurgias > 3 h: Manorapid® > PVPI 7,5% ou CHG
4%
Álcool etílico 61% + CHG 1% = CHG 4%
Efeito residual do CHG 4% > álcool etílico 61% + CHG
1%
Avagard® > Hibiclens® > álcool etílico 61%
Álcool etílico 61% não atingiu os critérios ASTM
para os dias 2º e 5º.
Efeito imediato: Sterillium® > Hibiscrub®
Efeito residual: Sterillium® = Hibiscrub®
Dia 1º e 2º: Triseptin® > Betadine®2 e Hibiclens®
Dia 5º: Triseptin® = Hibiclens® > Betadine®2
Betadine®2 sem efeito cumulativo.
Triseptin® aplicado com escova = esponja = somente c/
as mãos
Resultados
*
Outro
A:52 pessoas
B:85 pessoas
EClRCeL
Nível I Moderado
E8
Outro
75 cirurgiões
EClRCC
Nível I Moderado
E7
ASTM
E6
Método
90 pessoas (18
por grupo)
Amostra/
Perdas ou
Exclusões
EClRL
Nível II-1 –
Moderado
Evidência
...continuação
1490
Rev Esc Enferm USP
2012; 46(6):1484-93
Taxa de
infecção do
sítio cirúrgico
18 membros
da equipe
cirúrgica/2
54 pacientes
18 profissionais
da equipe
cirúrgica
Outro
(compara
60 pessoas
contagem
(membros de
microbiana após
equipe cirúrgica) antissepsia com e
sem uso de anel)
2084 cirurgias
para PT, 2175
cirurgias para PA,
todos os membros
da equipe
cirúrgica
EClRpCeCC
Nível I –
Moderado
EClCC
Nível II-1 –
Moderado
EClRpCeL
Nível I –
Moderado
ECoReCC
Nível II-2 –
Moderado
E18
E19
E20
E21
-
Imediatamente
após.
Antes, 1 min e
6h após nos dias
1º, 2º e 5º
Antes, imediatamente após,
após 2h, 4h e ao
final da cirurgia.
-
CHG 0,5%.
Triseptin®, Avagard®.
Sterillium® 2x6mL
+ 3mL nas trocas de
luvas.
Avagard® 3x 2mL,
Triseptin® por 3 min.
Avagard® 2x3mL (2
min).
10 estudos [1 analisando infecção do sítio cirúrgico com preparação alcoólica e tradicional (E12), 6 comparando preparação alcoólica com produto tradicional (E7, E12, E16, E18, Estudo não
selecionado para esta pesquisa por usar CHX antes da preparação à base de álcoola, Estudo não encontrado pelas autorasb)]
a. Pereira LJ, Lee GM, Wade KJ. An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts. Journal of Hospital Infection 1997; Vol. 36:49-65.
b. Herruzo Cabrera R, Vizcaino Alcaide MJ, Fdez Acinero MJ. Usefulness of an alcohol solution of NDuopropenide for the surgical antisepsis of the hands compared with handwashing with
iodine povidone and chlorhexidine. Journal of Surgical Research 2000; Vol. 94:6-12.
RevS (ECRCC)
Bom
R2
Avagard® = escova impregnada com produto
tradicional
3 estudos [2 comparando preparação alcoólica com produto tradicional (E9 e E10)]
Escova impregnada com produto
tradicional (6 min).
RevS (ECRCC)
Moderado
Avagard® 2x3mL (2
min).
R1
-
Outro
3600 pacientes
(1800 em cada
grupo)
1 cirurgião
ECoReCC
Nível II-2 –
Ruim
E23
Taxa de
infecção do
sítio cirúrgico
Outro
Aplicação por 3 min: Sterillium® > Betadine®1
Sterillium® por 3min = Sterillium® por 1,5 min
Álcool etílico 70% + CHG 0,5% = produto tradicional
Avagard® com anel = Avagard® sem anel
Triseptin com anel = Triseptin® sem anel
BD E-Z Scrub 205 com anel > BD E-Z Scrub 205®
sem anel.
Com e sem anel: Avagard® > Triseptin® = BD E-Z
Scrub 205®
Sterillium® = Hibiscrub® = Betadine®1
Avagard® e Triseptin® = PVPI
Somente Avagard® apresentou efeito cumulativo.
Avagard® = escova impregnada com produto
tradicional
CHG > Álcool 70% + CHG 0,5% (gel)
1-propanol 60% > álcool etílico 85% > 2-propanol
70% > CHG 4%.
Resultados
19 cirurgiões, 25
cirurgias cada
produto
Betadine®1 por 3 min.
Não cita.
BD E-Z Scrub 205®.
Hibiscrub®, Betadine®1 por 3 min.
PVPI 7,5% por 6 a 10 min.
Escova impregnada com produto
tradicional (2 a 5 min).
CHG por 5 min em todas as 1ªs
antissepsias, e por 3 min nas demais.
CHG 4% por 3min.
Produto tradicional
EClpCeCA
Nível II-1 –
Moderado
Fricção das
Antes, 1min
Sterillium® por 3 min
pontas dos
após
e
ao
final
da
(10,5mL)
e 1,5 min
dedos e da
cirurgia.
(6mL).
palma da mão
Fricção das
pontas dos
dedos
Glove juice
Taxa de
infecção do
sítio cirúrgico
Álcool 70% + CHG
0,5% (gel) por 3 min.
2-propanol 70% v/v,
álcool etílico 85% v/v,
1-propanol 60% v/v por
3 min.
Produto a base de
álcool
E22
Outro
Outro
ASTM
Outro
Ao final da
cirurgia.
Antes, 1min
após.
Tempo de
obtenção da
amostra
triseptin®: álcool etílico 70% + piritionato de zinco
Sterillium®: 2-propanol 45% + 1-propanol 30% +
mecetrônio etilsulfato 0,2%
Avagard®: álcool etílico 61% + chg 1%
manorapid®: isopropanol 70% + butanodiol 0,1% + lanolina 0,06%
Softa man®: álcool etílico 45% +
1-propanol 18%
Phisohex®: hexaclorofeno 3% com creme + detergente aniônico
disadine®: não cita formulação
irgasan 2% dP 300®: não cita formulação
betadine®1: pvpi 4%
betadine®2: pvpi 7,5%
Hibiclens®: chg 4%
Hibiscrub®: chg 4%
derman Plus®: triclosan 1%
bd E-Z Scrub 205®: 1% pvpi disponível
*
Glove juice
1100 pacientes
(550 por grupo)
1 cirurgião
ECoReCC
Nível II-2 –
Ruim
Fricção das
pontas dos
dedos
E17
Outro
41 cirurgias e
82 antissepsias
das mãos/2
antissepsias
EClRpCeCC
Nível I – Ruim
Fricção das
pontas dos
dedos
E16
EN12791
Técnica de
obtenção
da amostra
microbiana
20 pessoas em
cada um dos 5
laboratórios
Método
EClRL
Nível I –
Moderado
Amostra/
Perdas ou
Exclusões
E15
Evidência
...continuação
No Brasil, não há até o momento estudos publicados
sobre esse tema nas fontes investigadas. A própria utilização do álcool para higienização simples das mãos, medida
eficaz e conhecida, tem sofrido resistência por parte dos
profissionais no país.
orgânica (no caso foram utilizados sangue de carneiro e
contaminação artificial das mãos com S. macescens ATCC
14756)(23). A OMS recomenda o uso de palito de unha,
mas não recomenda o uso de escova para as unhas, devido seu caráter abrasivo(14).
O emprego de metodologias oficiais, publicadas por organizações reconhecidas, para avaliar a eficácia de antissépticos para o preparo cirúrgico das mãos foi fundamental na
realização da presente revisão sistemática. Testes padronizados e oficiais além de permitirem comparação entre resultados proporcionam maior confiabilidade aos mesmos. Dos
25 trabalhos analisados, seis (24%) utilizaram metodologias
oficiais, sendo quatro da ASTM (E6, E8, E11, E18) e dois da
prEN 12791 ou EN 12791 (E13, E15, respectivamente).
O tempo de aplicação/contato dos produtos tradicionais
foi entre 2 a 10 minutos. Já para as preparações alcoólicas, o
tempo variou de 1,5 a 5 minutos e na descrição da aplicação
do produto, muitos deram ênfase ao tempo de aplicação/
contato em detrimento da quantidade, que pode variar com
o tamanho da superfície de aplicação. Em apenas um estudo
(E2) houve testes com tempos menores, como 30 segundos.
Os dois estudos de revisão sistemática (8,0% - R1 e R2)
localizados, apesar de não serem exclusivos para antissepsia cirúrgica das mãos com preparações alcoólicas em
comparação com produtos tradicionais, avaliaram estudos randomizados controlados realizados em campo com
a mesma finalidade desta pesquisa.
A contagem microbiana ou sua redução foram os desfechos analisados pela maioria dos estudos selecionados
(78,3%). Doze estudos (60,0%) analisaram o efeito imediato e residual dos produtos (E3B, E4, E5, E6, E7, E8, E10,
E11, E13, E18, E19, E22), cinco (25,0%) apenas o efeito
imediato (E2, E3A, E9, E15, E20), três estudos (15,0%)
somente o efeito residual (E1, E3C, E16), oito (40,0%) o
efeito cumulativo (E3A, E4, E5, E6, E8, E9, E11, E18) e quatro (20,0%) não colheram amostras antes da antissepsia
para fins comparativos (E1, E3C, E16, E20). Cinco estudos
(21,7% - E12, E14, E17, E21, E23) utilizaram como desfecho a taxa de infecções do sítio cirúrgico.
Os métodos de coleta das amostras microbianas variaram, sendo os principais o “glove juice” e a impressão/
contato das pontas dos dedos em meio de cultura. Os estudos mais antigos utilizaram a lavagem das mãos com solução Ringer e a cultura de alíquotas dessa solução.
Ainda sobre a técnica utilizada, 14 estudos relataram
algum preparo das mãos antes da utilização do produto
(60,9%), sendo que em oito estudos (34,8% - E5, E6, E8,
E10, E11, E14, E18, E19) os espaços subungueais foram
limpos antes do procedimento de antissepsia cirúrgica,
com escovação ou uso de palito de unha. A necessidade
ou não de escovação ou uso de palito no espaço subungueal para sua limpeza antes da utilização da preparação
alcoólica, no parecer das autoras, ainda é uma lacuna
existente sobre o tema pelo seu caráter abrasivo à pele.
Nos estudos selecionados não fica claro qual o impacto
desse procedimento sobre a redução da microbiota da
pele após a antissepsia química. Sabe-se que esta é uma
região que acumula sujidade e consequentemente micro-organismos(13), contudo um estudo realizado com uma
modificação da metodologia oficial européia, a EN 1500,
mostra que o álcool nas formulações gel e líquida tem
ação microbicida na pele mesmo na presença de matéria
As preparações alcoólicas apresentam menor tempo
de aplicação/contato em relação aos produtos tradicionais, devido seu rápido efeito antimicrobiano o que otimiza o tempo dos profissionais e os recursos hospitalares
(E1)(15), aspecto que pode ser muito útil entre cirurgias
rápidas (oftalmológicas, por exemplo) que são realizadas
subsequentemente pela equipe cirúrgica. Em alguns países - onde a prática da utilização de preparação alcoólica
na antissepsia cirúrgica das mãos já é aceita -, existem estudos que têm avaliado a redução do tempo de contato
com esses produtos, porém não foram incluídos por não
atenderem aos critérios de inclusão dessa pesquisa.
Apesar da aceitação europeia de preparação alcoólica
na antissepsia cirúrgica das mãos, pesquisa realizada no
Reino Unido (2007) mostrou que o método tradicional
ainda é o mais utilizado (representando 90% na primeira
antissepsia do dia) e a preparação alcoólica é utilizada repetidamente em apenas 20% dos casos(24).
As preparações alcoólicas apresentam como vantagem a economia de água e custos. Devido seu método
de aplicação — apenas fricção sobre a pele, não necessita de enxágue, consequentemente dispensa o controle
rigoroso da qualidade da água, como utilização de filtros,
não usa toalha/compressa esterilizada. Estudos como o
(E9), mostram que as preparações alcoólicas promovem
uma redução dos custos por procedimento em até 67%
em relação aos produtos tradicionais(25). Sob o ponto de
vista ecológico, há economia considerável de água, além
de dispensar a estrutura de lavabo na unidade de centro
cirúrgico. Estudo realizado no Reino Unido, contabilizou a
quantidade de água utilizada para a antissepsia cirúrgica
das mãos com CHG ou PVPI, chegando a 18,5 L por procedimento e 931,938 L de água gastos por ano(26).
A principal desvantagem do álcool é seu efeito ressecante sobre a pele, que pode ser contornado com a adição de
emolientes, umectantes ou outros condicionantes à formulação(8,15). Estudos que avaliaram o efeito da preparação alcoólica e dos produtos tradicionais sobre a pele mostraram que
as preparações alcoólicas, com a adição de emolientes, ou
não em alguns estudos (E8), apresentam de maneira geral,
um efeito melhor ou similar à pele em comparação aos produtos tradicionais (E7, E8, E9, E10, E12, E18, E19). Por esse
motivo e devido ao método de aplicação, houve uma meRev Esc Enferm USP
2012; 46(6):1484-93
1491
lhor aceitação pelos profissionais (E9, E12, E18, E19). Ainda
sobre as características negativas do álcool, alguns estudos
reportaram o cheiro forte e, em alguns casos, sensação de
queimação/ardência nas mãos (E18), que pode ocorrer se
aplicado em soluções de continuidade da pele(8). Já os produtos tradicionais, na maioria dos casos, pioraram os aspectos
da pele e em alguns casos houve efeitos adversos (E7, E8, E9,
E12, E18, E19). Outras desvantagens das preparações alcoólicas são sua natureza volátil, precisando de atenção especial
para o recipiente e local de armazenamento; necessidade
de secar completamente após aplicação; e por não ter ação
surfactante, há a necessidade de lavar as mãos com água e
sabonete quando estas estiverem visivelmente sujas (E18).
Finalmente, com relação à eficácia antimicrobiana,
90,5% dos estudos relataram que as preparações alcoólicas tiveram redução microbiana maior (17 estudos — E1,
E2A, E3A, E3B, E3C, E4, E5, E6, E7, E8, E9, E10 para cirurgias maiores de 3hs, E11, E13, E15, E18, E22) ou igual (seis
estudos — E2B, E3A, E10 para cirurgias menores de 2hs,
E13, E19, E20) aos produtos tradicionais, sendo que em
quatro destes, o resultado variou entre maior ou igual dependendo do produto tradicional e/ou da preparação alcoólica (E2A, E2B, E3A, E13). Quatro estudos 19,0% — (E1,
E3B, E8, E16) mostraram a ineficácia do álcool quando
comparado ao produto tradicional, porém no (E1) o produto tradicional, é o hexaclorofeno, atualmente proibido
no Brasil devido seu efeito tóxico; o (E3B) não apresenta
análise estatística (somente valores absolutos); no (E8) o
álcool etílico 61% como único princípio ativo foi inferior
ao CHG 4%, já o álcool etílico 61% com CHG 1% foi melhor; e o (E16) não utilizou neutralizante no meio de cultura, caracterizando um importante viés do estudo.
O álcool isoladamente não apresenta efeito residual, apesar disso, a recuperação da microbiota da pele ocorre lentamente, pela contínua morte dos microorganismos e provavelmente devido ao efeito sub-letal em algumas bactérias da
pele(8,14-15). Contudo, a adição de outros antissépticos de ação
sinérgica em pequenas concentrações — como compostos
de quaternário de amônio, hexaclorofeno ou clorexidina —
às preparações alcoólicas confere ao álcool efeito residual, e
foram utilizados na maioria dos estudos analisados.
Todos os estudos que tiveram como medida de desfecho as taxas de ISC (E12, E14, E17,E21,E23) apresentaram
resultados que comprovam que não há diferença estatisticamente significante entre as preparações alcoólicas e os
produtos tradicionais utilizados.
A eficácia antimicrobiana de preparação alcoólica na
antissepsia cirúrgica das mãos depende do tipo de álcool
utilizado, da concentração e do tempo de contato. Nesse
sentido, para utilização em território nacional, é importante a elaboração de normas e teste de validação da eficácia antimicrobiana desses produtos e que estes sejam
registrados pela ANVISA, já que atualmente não existe
uma regulamentação nacional para preparação alcoólica
com essa finalidade. Devemos ampliar as atuais discus-
1492
Rev Esc Enferm USP
2012; 46(6):1484-93
sões sobre higienização das mãos com preparação alcoólica (como a obrigatoriedade da disposição de preparação
alcoólica para fricção antisséptica das mãos nos serviços
de Saúde do Brasil(27)) na antissepsia cirúrgica das mãos.
Em alguns estudos (E6, E11, E18) que adotaram a
metodologia ASTM, as preparações tradicionais não atingiram todos os critérios (níveis de redução microbiana)
exigidos pelo método, o que gera um questionamento sobre a eficácia desses produtos já amplamente utilizados e
aceitos ou sobre os padrões de redução microbiana exigidos por essa metodologia.
Em relação à qualidade dos estudos, das revisões sistemáticas (6,9%), a R1 foi classificada como moderado devido ao pequeno número de estudos e por não apresentar
as formulações alcoólicas utilizadas nos estudos, e a R2
como bom. Doze estudos foram classificados como Nível I
(41,4%), variando quanto à validade interna, onde um estudo foi classificado como categoria bom (E12); 10 como
categoria moderado (E2A, E5, E7, E8, E9, E11, E13, E15,
E18, E20); e um como categoria ruim (E16) por não utilizar
neutralizante na amostra. Onze estudos foram classificados
como Nível II-1 (37,9%), sendo seis da categoria moderado
(E1A, E3A, E6, E10, E19, E22) e cinco ruins (E1B, E2B, E3B,
E3C, E4) por não apresentarem análise estatística. Nesse tipo de experimento, para testar produtos com naturezas de
aplicação diferentes (somente fricção para o álcool ou técnica tradicional com produto que contém detergente para
os PT) é muito difícil conduzir investigações duplo-cegas,
justificando poucos estudos na categoria bom nos Níveis I e
II-1, além de somente um estudo (E12) ter realizado análise
intent-to-treat. Os demais estudos (quatro - 13,8%) foram
classificados como Nível II-2, sendo um da categoria moderado (E21) e três categorias ruins (E14, E17, E23) por não
considerarem as variáveis envolvidas na ISC.
concLUSão
Esta revisão sistemática permitiu concluir que há evidências científicas sobre a segurança do uso de preparação alcoólica (PA) para a antissepsia cirúrgica das mãos,
podendo, portanto, substituir a técnica tradicional com
CHG ou PVPI contendo detergente, ressaltando que a eficácia do álcool depende de seu tipo, concentração e tempo de contato. Os resultados obtidos vão ao encontro das
atuais recomendações da OMS e do CDC, além de obter
os mesmos resultados de outros estudos já realizados, como as duas revisões sistemáticas incluídas nessa pesquisa.
Para que uma mudança ocorra na prática, é necessária
a divulgação de novas pesquisas, oferecendo informações
sobre os benefícios com base em evidências científicas.
No caso da antissepsia com PA, a conscientização dos profissionais deve abranger além da efetividade desse produto para essa finalidade, seus benefícios em relação à
redução de custos, economia de água, menor tempo de
aplicação, menor efeito lesivo à pele e ganhos ecológicos.
REFERÊnciAS
1. Sparling KW, Ryckman FC, Schoettker PJ, Byczkowski TL, Helpling
A, Mandel K, et al. Financial impact of failing to prevent surgical
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14. World Health Organization (WHO). WHO guidelines on hand
hygiene in health care. First global patient safety challenge.
Clean care is safe care. Geneva; 2009.
2. Grinbaum RS, Mendonça JS, Cardo DM. An outbreak of handscrubbing-related surgical site infections in vascular surgical procedures. Infect Control Hosp Epidemiol. 1995;16(4):198-202.
15. Gruendemann BJ, Bjerke NB. Is it time for brushless scrubbing
with an alcohol-based agent? AORN J. 2001;74(6):859-73.
3. Isenberg HD, Tucci V, Cintron F, Singer C, Weinstein GS, Tyras
DH. Single-source outbreak of Candida tropicalis complicating
coronary bypass surgery. J Clin Microbiol. 1989;27(11):2426-8.
4. McNeil SA, Nordstrom-Lerner L, Malani PN, Zervos M, Kauffman CA. Outbreak of sternal surgical site infections due
to Pseudomonas aeruginosa traced to a scrub nurse with
onychomycosis. Clin Infect Dis. 2001;33(3):317-23.
5. Monteiro CEC, Lacerda RA, Paz MSO, Conceição VP. Paramentação cirúrgica: avaliação de sua adequação para a prevenção
de riscos biológicos em cirurgias. Parte II: os componentes da
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6. Widmer AF, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce
J, et al. Surgical hand preparation: state-of-the-art. J Hosp Infect. 2010;74(2):112-22.
7. Misteli H, Weber WP, Reck S, Rosenthal R, Zwahlen M, Fueglistaler P, et al. Surgical glove perforation and the risk of surgical
site infection. Arch Surg. 2009;144(6):553-8.
8. Brasil. Ministério da Saúde; Agência Nacional de Vigilância Sanitária (ANVISA). Segurança do paciente em Serviços de Saúde: higienização das mãos. Brasília; 2009.
9. Trampuz A, Widmer AF. Hand hygiene: a frequently missed
lifesaving opportunity during patient care. Mayo Clin Proc.
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10. Widmer AF. Replace hand washing with use of a waterless
alcohol hand rub? Clin Infect Dis. 2000;31(1):136-43.
11. Weber WP, Reck S, Neff U, Saccilotto R, Dangel M, Rotter ML,
et al. Surgical hand antisepsis with alcohol-based hand rub:
comparison of effectiveness after 1.5 and 3 minutes of application. Infect Control Hosp Epidemiol. 2009;30(5):420-6.
12. Department of Health and Human Services; Food and Drug
Administration. Tentative final monograph for health care
antiseptic products; proposed rule. Federal Register [Internet]. 1994 [cited 2011 May 25];59(116):31401-52. Available from: http://www.fda.gov/ohrms/dockets/ac/05/
briefing/2005-4098B1_02_03-FDA-TAB1.pdf
13. Boyce JM, Pittet D; Healthcare Infection Control Practices
Advisory Committee. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/
SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep. 2002;51(RR-16):1-45.
Revisão sistemática sobre
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de carvalho
Aguiar, 419
cerqueira
césar
Gonçalves
KJ, Graziano
KU, Kawagoe
JY brasil
cep
05403-000
- são
paulo, sp,
16. European Standards. CSN EN 12791. Chemical disinfectants
and antiseptics - Surgical hand disinfection - Test method
and requirements (phase2/step2). Brussels; 2005.
17. International Standards Worldwide. ASTM E 1115 - 11.
Standard Test Method for Evaluation of Surgical Hand Scrub
Formulations [Internet]. West Conshohocken; 2011 [cited
2011 May 26]. Available from: http://enterprise.astm.org/
filtrexx40.cgi?+REDLINE_PAGES/E1115.htm
18. Greer RB 3rd. The ritual at the scrub sink. Orthop Rev.
1994;23(2):97.
19. Evidence-Based Working Group. Evidence-based medicine:
a new approach to teaching the practice of medicine. JAMA.
1992;268(17):2420-5.
20. Galvão CM, Sawada NO, Trevizan MA. Revisão sistemática: recurso que proporciona a incorporação das evidências na prática da enfermagem. Rev Latino Am Enferm. 2004;12(3):549-56.
21. Mendonça SHF. Impacto do uso de conectores sem agulha
para sistema fechado de infusão na ocorrência de infecção
de corrente sanguínea relacionada ao cateter venoso central:
evidências de uma Revisão Sistemática [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2008.
22. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al.; Methods Work Group, Third US Preventive
Services Task Force. Current methods of the US Preventive
Services Task Force: a review of the process. Am J Prev Med.
2001;20(3 Suppl):21-35.
23. Kawagoe JY, Graziano KU, Martino MDV, Siqueira I, Correa L.
Bacterial reduction of alcohol-based liquid and gel products on
hands soiled with blood. Am J Infect Control. 2011;39(9):785-7.
24. Tanner J, Blunsden C, Fakis A. National survey of hand antisepsis practices. J Perioper Pract. 2007;17(1):27-37.
25. Tavolacci MP, Pitrou I, Merle V, Haghighat S, Thillard D, Czernichow P. Surgical hand rubbing compared with surgical
hand scrubbing: comparison of efficacy and costs. J Hosp
Infect. 2006;63(1):55-9.
26. Jehle K, Jarrett N, Matthews S. Clean and green: saving water
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27. Brasil. Ministério da Saúde; Agência Nacional de Vigilância
Sanitária. Resolução n. 42, de 25 de outubro de 2010. Dispõe sobre obrigatoriedade de disponibilização de preparação alcoólica para fricção antisséptica das mãos, pelos serviços de saúde do País, e dá outras providências. Diário Oficial
da União, Brasília, 26 out. 2010. Seção 1, p. 27.
Rev Esc Enferm USP
2012; 46(6):1484-93
1493
Journal of Microbiology, Immunology and Infection (2015) 48, 322e328
ScienceDirect
journal homepage: www.e-jmii.com
ORIGINAL ARTICLE
Comparative antimicrobial efficacy of
alcohol-based hand rub and conventional
surgical scrub in a medical center
Ni-Jiin Shen a, Sung-Ching Pan a,b, Wang-Huei Sheng a,b,*,
Kwei-Lian Tien b, Mei-Ling Chen b, Shan-Chwen Chang b,c,
Yee-Chun Chen a,b,c
a
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan
c
Department of Medicine, National Taiwan University, College of Medicine, Taipei, Taiwan
b
Received 29 April 2013; received in revised form 30 July 2013; accepted 13 August 2013
Available online 21 September 2013
KEYWORDS
Alcohol-based hand
rub;
Surgical antisepsis;
Surgical site infection
Background: Hand hygiene is the cornerstone of aseptic techniques to reduce surgical site
infection. Conventional surgical scrub is effective for disinfecting a surgeon’s hands. However,
the compliance of conventional scrub may be hindered by skin damage, allergy, and time.
Alcohol-based hand rub has a satisfactory antimicrobial effect, but mostly in laboratory settings. Our aim was to compare a conventional surgical scrub with an alcohol-based hand rub
to evaluate antimicrobial efficacy.
Methods: From June 1, 2010 to July 31, 2011, 128 healthcare workers were enrolled in the
study. They used an alcohol-based hand rub or a conventional surgical scrub as preoperative
hand antisepsis during their routine practice. Hand sampling for cultures were performed
before and after operations. Positive culture plates were further processed for pathogen identification.
Results: The culture positive rate of the alcohol-based hand rub was 6.2% before operations
and 10.8% after operations. Both rates were lower than the conventional surgical scrub
[47.6% before operations (p < 0.001) and 25.4% after operations (p Z 0.03)]. The most identified pathogens were Gram-positive with coagulase-negative staphylococci being the major
pathogen. Multivariate analysis showed that prior hand condition (p Z 0.21) and type of surgery such as cardiovascular surgery (p Z 0.12) were less relevant, but the alcohol-based hand
rub was a significant protective factor for positive hand cultures.
* Corresponding author. Department of Internal Medicine, National Taiwan University Hospital, Number 7, Chung-Shan South Road, Taipei
100, Taiwan.
E-mail address: [email protected] (W.-H. Sheng).
1684-1182/$36 Copyright ª 2013, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jmii.2013.08.005
Efficacy of alcohol-based hand rub
323
Conclusion: The alcohol-based hand rub was more efficacious for surgical antisepsis and had
sustained efficacy, compared to conventional surgical scrub. We suggest that alcohol-based
hand rubs could be an alternative surgical antiseptic in the operative theater.
Copyright ª 2013, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights
reserved.
Introduction
Surgical site infection is a globally recognized problem that
results in significant morbidity.1 Joseph Lister was among
the first to demonstrate the effect of skin disinfection on
reducing surgical site infections.2 Thus, washing hands with
antimicrobial soaps, warm water, and frequently with a
brush became the primary protocol for surgical hand
preparation. Antiseptic soaps should rapidly eliminate
transient skin flora and reduce resident flora on the hands
to a minimum during a surgical procedure, and thus lower
the risk of surgical site contamination if surgical gloves are
perforated or torn during surgery.3
Conventional surgical hand antisepsis consists of an
aqueous scrub with a brush by using povidone iodine (PVP-I)
or chlorhexidine-based detergents. However, scrubbing
with these detergents strips skin oils, compromises skin
integrity, and (if a brush is used) often causes microabrasions, thereby increasing the risk of subsequent colonization by pathogens.4 As a result, conventional surgical
scrub has the disadvantages of skin damage and allergic
skin reaction. It is also time consuming to use them. In the
laboratory setting, an alcohol-based hand rub is as effective as conventional surgical scrub in its antimicrobial
ability.5,6 In addition, skin irritation or dermatitis happened
less frequently with an alcohol-based hand rub in a small
series of case studies. This can also help increase the
compliance of hand washing by healthcare providers in
hospitals.7e9
Several alcohol-based hand rubs have been licensed for
the commercial market, although there are few clinical
studies to compare the antisepsis efficacy against conventional surgical scrub in a routine operating practice environment.10,11 The World Health Organization (WHO)
guidelines also state that surgical antisepsis is a state of
art, suggesting that there are no optimal antiseptics.12 We
conducted a prospective, observational study in our hospital with the aim of comparing a conventional surgical
scrub with an alcohol-based hand rub to evaluate their
antisepsis efficacy before and after operations.
Materials and methods
Hospital setting
The National Taiwan University Hospital (NTUH) is a medical
center with 2388 beds. It comprises three operation theaters
with 52 functioning operating rooms (including five delivery
rooms). More than 140 surgical procedures were performed
daily during 2010 and 2011. The entrance of each operating
room is equipped with a sensor sink or a step-operated sink
that contains two sets of antisepsis scrubbing facilities. The
study was approved by the surgical committee and by the
institutional review board of the National Taiwan University
Hospital (NTUH-IRB; No. 201109015RC).
Inclusion criteria
This prospective observational study was conducted from
June 1, 2010 to July 31, 2011. The volunteer participants
were practicing doctors and nurses who had previous
experience with the conventional surgical scrub protocol in
the operating environment. They were allocated to the
intervention group (i.e., alcohol-based hand rub) or the
control group (i.e., conventional surgical scrub), based on
their choice (rather than by randomization). All participants were educated and rehearsed in the alcohol-based
hand rub protocol prior to this study. The participants’
characteristics such as having an allergy to conventional
surgical scrub or having wounds on their hands and the
characteristics of the surgeries such as surgical specialty,
surgical site, surgical wound classification, type of surgery,
blood loss amount, operation duration, and glove wearing
duration were recorded.
Exclusion criteria
Participants were excluded if they did not complete
providing samples for culture before the operation (T0) and
after the operation (T1). Participants with missing baseline
characteristics data were also excluded.
Hand preparation and sampling
The alcohol-based hand rub contained 1% chlorhexidine
gluconate and 61% ethyl alcohol (Avagard; 3M, MN, USA).
The standard hand rub protocol was as follows: (1) one
pump (2 mL) of lotion was dispensed into the palm of the
left hand; (2) the fingertips of the right hand were dipped
into the lotion to decontaminate under the nails; (3) the
remaining lotion was spread over the right hand and up to
just above the elbow; and (4) a second pump (2 mL) of
lotion was then placed into the palm of the right hand. This
process was repeated by dipping the fingers tip of the left
hand into the lotion, followed by spreading it over the left
hand and up to just below the elbow. Another 2 mL of lotion
was finally placed into cupped hands and reapplied to all
aspects of the hands up to the wrists. This solution was then
allowed to dry. The three-step application of the alcoholbased hand rub (Avagard) was completed within 2 minutes.
The conventional surgical scrub contained 4% chlorhexidine gluconate (Hibiscrub; Janson’s Medical Co., Taipei,
324
N.-J. Shen et al.
Taiwan) or 7.5% povidone-iodine. The standard conventional surgical scrub protocol was as follows: (1) three full
squirts (6 mL) of PVP-I or chlorhexidine were placed into
the cupped hands; (2) this was followed by a five-minute
hand scrubbing just up to the elbow by using a sterile scrub
brush; and (3) the lotion was rinsed away by tap water. All
aforementioned steps were repeated, except the hands
were dried with sterile towels, instead of being rinsed with
tap water, to avoid recontamination.
After hand scrubbing or rubbing protocol, every participant was sampled immediately before the operation (T0).
They then performed the scheduled operations. Another
sample was obtained after the operation (T1). We used
normal saline-moistened sterile cotton swabs to obtain
Table 1
specimens for cultures by wiping through every part of the
hand (including the ventral and dorsal side of the hands),
the fingertips, and the lateral sides of the fingers and the
wrists. The samples were immediately inoculated onto 5%
sheep blood agar plates.
Microbiology
The causative pathogens were identified with conventional
methods in accordance with the Clinical Laboratory Standard Institute (CLSI) guidelines.13 The 5% sheep blood agar
culture plates were maintained at 37! C until sufficient
growth had occurred. The plates were subsequently read by
a bacteriologist who was blinded to the method of
Baseline characteristics of participants in the alcohol-based hand rub and the conventional surgical scrub groups
Healthcare workers
Attending physician
Residents
Interns
Nurses
Allergy to povidone-iodine
Presence of wounds on hand
Have both allergy to povidone-iodine and
presence of wounds on hand
Surgeon specialty
General surgery
Chest surgery
Cardiovascular surgery
Plastic surgery
Neurosurgery
Ear-nose-throat surgery
Ophthalmologic surgery
Orthopedic surgery
Urologic surgery
Surgical site
Head
Chest
Abdomen
Pelvis
Spine
Extremities
Wound classification
Clean
Clean-contaminated
Contaminated
Type of surgery
Emergency
Elective
Blood loss amount, median (mL)
Blood loss amount > 300 mL
Surgery duration, median (min)
Gloves wearing duration, median (min)
Attending physician
Resident physician
Intern
Operating room nurse
Total
Alcohol-based
hand rub
Conventional surgical
scrub
128
22
52
9
45
15
23
10
65
13
24
3
25
12
10
8
63
9
28
6
20
3
13
2
0.392
0.386
0.320
0.426
0.025
0.439
0.096
40
16
17
11
9
13
3
6
13
21
7
10
4
0
7
2
6
8
19
9
7
7
9
6
1
0
5
0.793
0.548
0.476
0.360
0.001
0.816
0.999
0.028
0.413
25
28
34
20
4
17
9
8
18
14
0
16
16
20
16
6
4
1
0.099
0.008
0.769
0.061
0.056
<0.001
81
45
2
48
15
2
33
30
0
0.012
0.004
0.496
0.016
2
63
10 (10e80)
9
70 (35e160)
80 (42e151)
66 (37e103)
79 (40e159)
103 (90e119)
90 (48e165)
10
53
20 (10e400)
16
140 (43e241)
105 (47e181)
135 (66e162)
105 (44e252)
59 (32e211)
113 (72e172)
12
116
10 (10e237.5)
25
105 (40e241)
96 (42e164)
84 (45e152)
100 (42e198)
77 (41e163)
102 (53e165)
p
0.036
0.099
0.071
0.072
0.102
0.174
0.439
0.392
Table 2
325
Comparison of the sample cultures and the identified pathogens before and after the operation
Before the operation (T0)
Positive rate (T0)
Identified pathogens
Gram-positive
Coagulase-negative
staphylococci
Bacillus
Staphylococcus aureus
Gram-positive bacilli
Micrococcus spp.
Corynebacterium spp.
Gram-negative
Rosemonas spp.
Acinetobacter baumannii
Moraxella spp.
Pseudomonas aeruginosa
Klebsiella oxytoca
Sphingomonas paucimobilis
Multi-pathogens
After the operation (T1)
Alcohol-based
hand rub
% (n/N )
Conventional
surgical scrub
% (n/N )
p
Alcohol-based
hand rub
% (n/N )
6.15 (4/65)
47.62 (30/63)
<0.001
10.77 (7/65)
25.4 (16/63)
0.031
6.15 (4/65)
1.54 (1/65)
42.86 (28/63)
42.86 (27/63)
<0.001
<0.001
1.54 (6/65)
6.15 (4/65)
23.81 (15/63)
14.29 (9/63)
0.026
0.152
1.54 (1/65)
3.17 (2/63)
0.616
1.54 (1/65)
1.54 (1/65)
0
3.17 (2/63)
0.999
0.616
1.54 (1/65)
0
3.17 (2/63)
1.59 (1/63)
0.616
0.492
1.54 (1/65)
1.54 (1/65)
0
0
0
1.54 (1/65)
1.59
3.17
1.59
3.17
1.59
3.17
(1/63)
(2/63)
(1/63)
(2/63)
(1/63)
(2/63)
0.999
0.616
0.492
0.24
0.492
0.616
0
0
1.59 (1/63)
1.59 (1/63)
0.492
0.492
3.17 (2/63)
0.999
0.24
0
1.54 (1/65)
1.59 (1/63)
0
0.492
0.999
1.54 (1/65)
4.76 (3/63)
0.361
1.54 (1/65)
0
Conventional
surgical scrub
% (n/N )
0
p
T0 Z before surgery; T1 Z after surgery.
antisepsis. The positive culture plates were further processed with standard biochemical methods to identify the
pathogens.
Statistical analysis
Data were analyzed by using the PASW Statistics version 18
software (SPSS Inc., Chicago, IL, USA). Proportion comparisons for categorical variables were performed by using Chisquare test. Fisher’s exact test was used when data were
sparse. Statistical significance was set at p < 0.05. Variants
with p < 0.05 or with clinical importance were further
taken into multivariate logistic regression model analysis by
using the backward selection to predict the protective
factors for positive sample cultures.
and 30.16% (control group); p Z 0.793; Table 1]. The
alcohol-based hand rub group was involved in more orthopedic surgeries than the conventional surgical scrub group
(p Z 0.002) and the conventional surgical scrub group was
involved in more neurologic surgeries than the interventional group (p Z 0.014). There was a significant difference
in the skin condition between the two groups for an allergic
reaction to the povidone-iodine scrub (p Z 0.016). The
median blood loss amount was 10 mL in the interventional
group and 20 mL in the control group (p Z 0.036). The
median surgery duration was 70 minutes in the interventional group and 140 minutes in the control group
(p Z 0.071). The median glove wearing duration was 80
minutes in the interventional group and 105 minutes in the
control group (p Z 0.072; Table 1). Of the sample cultures
Results
During the study period, 154 healthcare providers were
invited. Twenty-six participants were excluded because of
not providing sample cultures after completing surgeries.
Therefore, 128 healthcare providers were enrolled for
analysisd65 participants were in the interventional group
and 63 participants were in the control group. In the
interventional group, there were 13 attending physicians,
24 residents, 3 interns, and 25 operating room nurses. In
the control group, there were 9 attending physicians, 28
residents, 6 interns, and 20 operating room nurses. There
were no significant differences in demographic characteristics between these two groups. However, surgical specialty was a variant, and most people in both groups were
involved in general surgery [32.31% (interventional group)
Figure 1. Positive rate of sample cultures obtained before
the operation and after the operation for alcohol-based hand
scrub and conventional surgical scrub groups.
326
N.-J. Shen et al.
interventional group were positive and 16 (25.40%) cultures
in the control group were positive with a clinically significant difference (p Z 0.031). In both groups, Gram-positive
pathogens comprised most of the identified pathogens.
There was no significant difference for other identified
pathogens (Table 2).
obtained before the operations (T0), four (6.15%) cultures
in the interventional group were positive and 30 (47.62%)
cultures in the control group were positive with a clinically
significant difference (p < 0.001). Most identified pathogens were Gram positive. Of the cultures sampled after
the operations (T1), seven (10.77%) cultures in the
Table 3
cultures
Risk factors for positive sample cultures by using multivariate regression analysis for the prediction of positive
Type of surgical hand antisepsis
Conventional surgical scrub
Sampling time
Healthcare workers
Attending physician
Residents
Interns
Nurses
Have both allergy to povidone-iodine
and presence of wounds on hand
Surgery specialty
General surgery
Chest surgery
Plastic surgery
Neurologic surgery
Orthopedic surgery
Urologic surgery
Surgical site
Head
Chest
Abdomen
Pelvis
Spine
Extremities
Clean
Clean-contaminated
Contaminated
Type of surgery
Emergent operation
Elective
Blood loss amount (mL)
Surgery duration (min)
Gloves wearing duration (min)
Attending physician
Residents
Interns
Nurses
Positive culture
(n Z 57)
Negative culture
(n Z 199)
Univariate analysis
p
Multivariate analysis
p
11
46
119
80
<0.001
<0.001
34
23
94
105
0.098
13
22
0
22
7
16
7
31
82
18
68
23
30
13
0.202
0.724
0.016
0.537
0.881
0.024
0.154
21
5
3
4
6
10
1
1
6
59
27
31
18
12
16
5
11
20
0.302
0.334
0.047
0.792
0.242
0.036
0.999
0.31
0.916
18
9
18
8
1
3
32
47
50
32
7
31
0.009
0.207
0.331
0.708
0.689
0.047
27
28
2
135
62
2
0.005
0.012
0.215
0.555
0.636
8
49
10 (10e200)
96 (40e238)
88 (47e154)
105 (66e151)
48 (40e141)
0
123 (67e178)
16
183
10 (10e250)
108 (40e241)
96 (45e170)
78 (40e153)
105 (42e206)
77 (44e148)
95 (48e160)
0.171
0.915
Data are presented as n or median (range).
NA Z non-applicable; T0 Z before surgery; T1 Z after surgery.
0.908
0.935
0.8
0.52
0.152
NA
0.31
0.998
0.543
0.210
0.119
0.499
0.726
0.463
The culture positive rate was higher in the control group
at T0 and at T1 (Fig. 1). We found a trend that the culturepositive rate of the interventional group increased from T0
to T1, whereas the trend of the control group declined from
T0 to T1.
For outcome analysis, 256 sample cultures were further
stratified according to culture results. We had 57 positive
sample cultures and 199 negative sample cultures. Most
sample cultures in the interventional arm had negative results with a significant difference (p < 0.001). All sample
cultures of the interns had negative results (p Z 0.019). We
also found that participants who were involved in cardiovascular surgeries had more negative sample cultures
(p Z 0.043), whereas participants who were involved in earnose-throat surgeries had more positive sample cultures
(p Z 0.036). The participants were more likely to have
positive sample cultures when they operated over the patient’s head (p Z 0.009), were involved in surgeries with
clean-contaminated wounds (p Z 0.012), or had wounds on
their hands (p Z 0.024). By contrast, participants were more
likely to have negative sample cultures when they operated
over a patient’s extremities (p Z 0.043) or were involved in
surgeries with clean wounds (p Z 0.005; Table 3). We used
variants with p < 0.05 or with clinical importance into
multivariate regression model analysis. Only the alcoholbased hand rub was a protective factor in the positive sample cultures (p < 0.001). Table 3 summarizes the results.
Discussion
In this prospective observational study, we found that the
two-minute three-step alcohol-based hand rub had a lower
culture positive rate before and after the operations. Our
results suggest that the alcohol-based hand rub is efficient
and less time consuming.
The increasing use of alcohol-based hand rubs has led to
trials studying its efficacy as an alternative to traditional hand
scrubbing for hand antisepsis. Olson et al14 conducted a prospective, randomized in vivo study and found that an alcoholbased hand rub was not inferior to alcohol-only products at all
sampling points. Burch et al10 compared the efficacy of an
alcohol-based hand rub to the traditional 4% chlorhexidine
scrub in a cardiac operating room environment. The alcoholbased hand rub showed no difference in comparison to the
traditional scrub. A larger study conducted by Weight et al15
evaluated the use of an alcohol-based hand rub or conventional surgical scrub as surgical antisepsis in 3600 pediatric
urological operations. The surgical site infection rates between the two groups were similar [2 of 1800 (alcohol-based
rub) procedures vs. 3 of 1800 procedures (conventional
scrub); p > 0.99]. The insignificant difference may have
resulted from the relatively low incidence of surgical site infections. A large sample size is needed to statistically reveal
the difference between the two types of hand rub.
Another reason for the insignificant difference may be that
a different measurement method was used. Larson et al16
focused on different bacterial colony-forming units,
whereas our study focused on a positive culture rate and on
identifying a specific pathogen. By contrast, our study chose
an intermediate end point (i.e., the positive rate of the hand
culture), which effectively revealed a significantly lower risk
327
of hand contamination before and after using an alcoholbased hand rub than after using a conventional PVP-I-based
or chlorhexidine-based hand rub. In addition, our study
involved the most common surgery specialties in the clinical
setting, instead of being limited to a specific surgical
department; this increased the generalizability of the study
results. The positive culture rate of our study was therefore
significantly lower with the alcohol-based hand rub. Between
the two different hand rub regimens, there was also no difference in the culture rate of highly pathogenic pathogens
(e.g., Staphylococcus aureus or Pseudomonas aeruginosa).
To date, few studies have evaluated the sustained effect
of alcohol-based hand rubs. Mulberry et al17 conducted two
randomized, blinded, well-controlled clinical studies
involving 137 healthy study participants and proved that the
antimicrobial effect of an alcohol-based hand rub could
persist more than 3 hours. Choi18 compared an alcohol-based
hand rub against a traditional 7.5% PVP-I scrub and found the
alcohol-based hand rub had a lower positive culture rate
after operations, compared to the traditional scrub.
In our study, the positive rate was higher after operations than before operations in the alcohol-based hand rub
group. This indicates that the sustained antimicrobial effect of the alcohol-based hand rub may be insufficient.
Our study has several limitations. First, our prospective
study was a nonrandomized cohort that used volunteer
participants. We also excluded volunteers who did not have
postoperative microbial surveillance. However, we adapted
a standardized sampling method and the microbiology results were observed by a microbiologist who was blinded to
the antiseptic regimens. In this way, we could reduce selection bias to a minimum. Second, the average operation
duration in our study was relatively short (median time, 1.5
hours). As a result, the data should be generalized with
caution for operations of longer duration. Third, our case
number was small. Large randomized studies on operations
with longer durations are furthermore needed.
In conclusion, our results showed that an alcohol-based
hand rub was more efficacious than a conventional surgical
scrub for surgical antisepsis with sustained efficacy. The
rapid bactericidal effect also suggested that an alcoholbased hand rub could be an alternative surgical antiseptic
in the operative theaters.
Conflict of interest
All authors declare that there is no conflict of interest.
Acknowledgments
We are grateful to the members of the operating theaters
for participating in this study.
References
1. Delgado-Rodriguez M, Gomez-Ortega A, Llorca J, Lecuona M,
Dierssen T, Sillero-Arenas M, et al. Nosocomial infection,
indices of intrinsic infection risk, and in-hospital mortality in
general surgery. J Hosp Infect 1999;41:203e11.
2. Keen WW. Before and after Lister. Science 1915;41:845e53.
328
3. Rotter ML. Alcohols for antisepsis of hands and skin. In:
Ascenzi JM, editor. Handbook of disinfectants and antiseptics.
New York: Marcel Dekker; 1996. p. 177e233.
4. Rotter ML. Hand washing and hand disinfection. In: Mayhall CG,
editor. Hospital epidemiology and infection control. 2nd ed.
Philadelphia PA: Lippincott Williams & Wilkins; 1999. p. 1339e55.
5. Gutierrez CB, Alvarez D, Rodriguez-Barbosa JI, Tascon RI, de la
Puente VA, Rodriguez-Ferri EF. In vitro efficacy of N-duopropenide, a recently developed disinfectant containing quaternary ammonium compounds, against selected gram-positive
and gram-negative organisms. Am J Vet Res 1999;60:481e4.
6. Herruzo-Cabrera
R,
Garcia-Caballero
J,
FernandezAcenero MJ. A new alcohol solution (N-duopropenide) for hygienic (or routine) hand disinfection is more useful than classic
handwashing: in vitro and in vivo studies in burn and other
intensive care units. Burns 2001;27:747e52.
7. Asensio A, de Gregorio L. Practical experience in a surgical unit
when changing from scrub to rub. J Hosp Infect 2013;83(Suppl. 1):
S40e2.
8. Kramer A, Bernig T, Kampf G. Clinical double-blind trial on the
dermal tolerance and user acceptability of six alcohol-based
hand disinfectants for hygienic hand disinfection. J Hosp
Infect 2002;51:114e20.
9. Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P,
Bensadoun H, et al. Hand-rubbing with an aqueous alcoholic
solution vs. traditional surgical hand-scrubbing and 30-day
surgical site infection rates: a randomized equivalence study.
JAMA 2002;288:722e7.
10. Burch TM, Stanger B, Mizuguchi KA, Zurakowski D, Reid SD. Is
alcohol-based hand disinfection equivalent to surgical scrub
N.-J. Shen et al.
11.
12.
13.
14.
15.
16.
17.
18.
before placing a central venous catheter? Anesth Analg 2012;
114:622e5.
Palmer JS. Use of Avagard in pediatric urologic procedures.
Urology 2006;68:655e7.
Pittet D, Allegranzi B, Boyce J. The World Health Organization
guidelines on hand hygiene in health care and their consensus
recommendations. Infect Control Hosp Epidemiol 2009;30:
611e22.
Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing:
twenty-first informational supplement M100eS2. Wayne, PA:
CLSI; 2011.
Olson LK, Morse DJ, Duley C, Savell BK. Prospective, randomized in vivo comparison of a dual-active waterless antiseptic
versus two alcohol-only waterless antiseptics for surgical hand
antisepsis. Am J Infect Control 2012;40:155e9.
Weight CJ, Lee MC, Palmer JS. Avagard hand antisepsis vs.
traditional scrub in 3600 pediatric urologic procedures. Urology 2010;76:15e7.
Larson EL, Aiello AE, Heilman JM, Lyle CT, Cronquist A,
Stahl JB, et al. Comparison of different regimens for surgical
hand preparation. AORN J 2001;73:412e4.
Mulberrry G, Snyder AT, Heilman J, Pyrek J, Stahl J. Evaluation
of a waterless, scrubless chlorhexidine gluconate/ethanol
surgical scrub for antimicrobial efficacy. Am J Infect Control
2001;29:377e82.
Choi JS. Evaluation of a waterless, scrubless chlorhexidine
gluconate/ethanol surgical scrub and povidone-iodine for
antimicrobial efficacy. Taehan Kanho Hakhoe Chi 2008;38:
39e44.
CONTINUING EDUCATION
Back to Basics: Hand
Hygiene and Surgical Hand
Antisepsis
1.2
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE
Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours
are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Event: #13533
Session: #0001
Fee: Members $7.20, Nonmembers $14.40
Dr Spruce has no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication of this
article.
The behavioral objectives for this program were created by
Kimberly Retzlaff, managing editor, with consultation from
Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan
Bakewell, MS, RN-BC, director, Perioperative Education. Ms
Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of
interest in the publication of this article.
The CE contact hours for this article expire November 30,
2016. Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge of best practices related
to hand hygiene and performing surgical hand antisepsis.
Conflict of Interest Disclosures
Objectives
1. Discuss common areas of concern that relate to perioperative best practices.
2. Discuss best practices that could enhance safety in the
perioperative area.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
Accreditation
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses
Credentialing Center approves or endorses products mentioned
in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.08.017
! AORN, Inc, 2013
November 2013
Vol 98 No 5 !
AORN Journal j 449
Back to Basics: Hand Hygiene and
Surgical Hand Antisepsis
1.2
www.aorn.org/CE
ABSTRACT
Health careeassociated infections (HAIs) are a significant issue in the United
States and throughout the world, but following proper hand hygiene practices is the
most effective and least expensive way to prevent HAIs. Hand hygiene is inexpensive and protects patients and health care personnel alike. The four general
types of hand hygiene that should be performed in the perioperative environment
are washing hands that are visibly soiled, hand hygiene using alcohol-based
products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based
surgical hand rub product. Barriers to proper hand hygiene may include not
thinking about it, forgetting, skin irritation, a lack of role models, or a lack of a
safety culture. One strategy for improving hand hygiene practices is monitoring
hand hygiene as part of a quality improvement project, but the most important
aspect for perioperative team members is to set an example for other team members
by following proper hand hygiene practices and reminding each other to perform
hand hygiene. AORN J 98 (November 2013) 450-457. ! AORN, Inc, 2013. http://
dx.doi.org/10.1016/j.aorn.2013.08.017
Key words: hand hygiene, surgical hand rub, surgical hand scrub, health caree
associated infection.
I
t is appropriate to begin this “Back to Basics”
series with hand hygiene and surgical hand
antisepsis, because these activities are the foundation of infection prevention for all perioperative
personnel. It is probably safe to say that anyone in
health care today has heard of the importance of
hand hygiene. Hand hygiene is the most effective
and least expensive way to prevent health caree
associated infections (HAIs).1 All health care
workers can prevent HAIs by washing their hands.
Health careeassociated infections are a major
problem in the United States and throughout the
world. In US hospitals, the most frequently occurring HAIs are urinary tract infections (36%),
surgical site infections (20%), and blood stream
infections and pneumonia (11%).2 The economic
effect of these infections was $6.5 billion in 20042
and reached $33.8 billion in 2009.3 Hand hygiene
practices can jeopardize safety in the perioperative
area if not performed as recommended; if performed correctly, hand hygiene can significantly improve the burden on the global health care system
by decreasing microorganism transmission to patients and health care workers.
HOW-TO GUIDE
The World Health Organization (WHO) Guidelines
on Hand Hygiene in Health Care state,
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BACK TO BASICS: HAND HYGIENE
Guidelines in the [United States] recommend
that agents used for surgical hand preparation
should significantly reduce microorganisms on
intact skin, contain a non-irritating antimicrobial preparation, have broad-spectrum activity,
and be fast-acting and persistent.2(p55)
A complete guide to products is included in the
WHO guidelines. However, there are basic types
of products that should be used in perioperative
settings. Alcohol-based hand rubs are the preferred type of product for hand hygiene, while
the recommended formulation for surgical hand
antisepsis products is more complex and there
are multiple antiseptic agents that fit this
category.2
The AORN “Recommended practices for hand
hygiene”1 recommends that hand hygiene should
be performed at numerous times:
n
n
n
n
n
n
n
n
n
n
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should be performed in the perioperative environment: washing hands that are visibly soiled, hand
hygiene using alcohol-based products, surgical
hand scrubs, and surgical hand scrubs using an
alcohol-based surgical hand rub product. There
are specific techniques for each of these types of
hand hygiene.
Washing Hands That Are Visibly Soiled
This type of hand hygiene should take 40 to 60
seconds to perform. According to WHO,2 health
care personnel should use the following 11-step
hand-washing process to ensure their hands are
properly cleaned (Figure 1). After wetting hands
with water, the following steps should be taken:
1. Apply enough soap to cover all hand surfaces;
2. Rub hands palm to palm;
3. Right palm over left dorsum with interlaced
fingers and vice versa;
4. Palm to palm with fingers interlaced;
5. Backs of fingers to opposing palms with fingers
interlocked;
6. Rotational rubbing of left thumb clasped in
right palm and vice versa;
on arrival at the facility,
before and after every patient contact,
before putting on gloves,
after removing gloves,
after removing personal protective equipment,
after possible contact with blood or other potentially infectious
materials,
before and after eating,
Resources for Hand Hygiene
before and after using the
Videos
restroom,
n Hygi!
ene des mains H^opitaux Universitaires de Gen!eve Vigi
before leaving the
Germe. http://youtu.be/0at_jtzJCDM.
facility, and
n WHO hand hygiene video. http://youtu.be/s08yiZBSGOw.
when hands are visibly
soiled.
Perioperative personnel
should review and be mindful
of these recommended practices and keep reminders of
them visible in a prominent
place to help ensure that
good practices become habit.
There are four general
types of hand hygiene that
Online resources
n Clean care is safer care. World Health Organization. http://
www.who.int/gpsc/5may/background/5moments/en.
n Hand hygiene in healthcare settings. Centers for Disease Control
and Prevention. http://www.cdc.gov/handhygiene/Resources
.html#HCP.
n How to wash your hands e hand washing techniques from the
NHS. NHS. http://www.wash-hands.com/resources.
Web site access verified August 12, 2013.
AORN Journal j 451
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Figure 1. How to Handwash. http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf ª World Health
Organization 2009. All rights reserved. Reprinted with permission.
452 j AORN Journal
7. Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa;
8. Rinse hands with water;
9. Dry hands thoroughly with a single use towel;
10. Use towel to turn off faucet;
11. Your hands are now safe.4
Hand Hygiene Using Alcohol-Based
Products
During situations in which hands are not visibly
soiled, such as after removing gloves or touching
a doorknob, perioperative team members should
use an alcohol-based hand rub for hand hygiene.
This type of hand hygiene process should take 20 to
30 seconds to complete. According to WHO, 2
perioperative team members should use an eightstep hand-rub process to ensure their hands are
properly cleaned (Figure 2). If visibly soiled,
hands and forearms should be prewashed with
plain soap and water or an antimicrobial agent,
and then the following steps should be taken:
1. Apply a palmful of the product in a cupped
hand, covering all surfaces;
interlocked;
and vice versa;
8. Once dry, your hands are safe.5
Surgical Hand Scrub
According to AORN,1 a surgical hand scrub should
be performed before donning sterile gloves for
surgical or other invasive procedures. This process is effective at a duration of three to five minutes. Perioperative team members should use the
www.aornjournal.org
following steps to ensure their hands are properly cleaned:
1. Remove jewelry including rings, watches, and
bracelets.
2. Don a surgical mask. If others are at the scrub
sink, a surgical mask should be worn in the
presence of hand scrub activity.
3. Wash hands and forearms if visibly soiled with
soap and running water immediately before
beginning the surgical scrub.
4. Clean the subungual areas of both hands under
running water using a disposable nail cleaner.
Discard the nail cleaner in the appropriate
container.
5. Rinse hands and forearms under running water.
6. Dispense the approved antimicrobial scrub
agent according to the manufacturer’s written
directions.
7. Apply the antimicrobial agent to wet hands and
forearms using a soft, nonabrasive sponge.
8. A three- or five-minute scrub should be timed
to allow adequate product contact with skin,
according to the manufacturer’s written
directions.
9. Visualize each finger, hand, and arm as having
four sides. Wash all four sides and the web
space, keeping the hand elevated. Repeat this
process for opposite fingers, hand, and arm.
10. For water conservation, turn water off when it
is not directly in use, if possible.
11. Avoid splashing surgical attire.
12. Discard sponges, if used, in appropriate
containers.
13. Hands and arms should be rinsed under running water in one direction from fingertips to
elbows as often as needed.
14. Hold hands higher than elbows and away from
surgical attire.
15. In the OR, beginning at the fingertips of one
hand and working up to the elbow with one end
of the towel and repeating the process with the
clean end of the towel on the other hand and
arm before discarding the towel and donning
a sterile surgical gown and gloves.1(p67)
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SPRUCE
Figure 2. How to Handrub. http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf ª World Health
454 j AORN Journal
www.aornjournal.org
Surgical Hand Scrub Using an AlcoholBased Surgical Hand Rub Product
According to AORN,1 an alcohol-based antiseptic
surgical hand rub with documented persistent and
cumulative activity that has met US Food and Drug
Administration regulatory requirements is acceptable. The WHO does not recommend a standardized process for the surgical hand scrub with an
alcohol-based product; however, the organization
does stress the importance of keeping the hands wet
with the product throughout the process.2 The
volume of product that should be used depends on
the size of the team member’s hands and forearms.
After the product is dispensed, the forearms should
be the focus of the rub for the first minute and then
the hands should be the focus, following the same
procedure outlined in the hand scrub technique. To
ensure their hands are properly cleaned, perioperative team members should use the following steps
during a surgical hand scrub using an alcohol-based
surgical hand rub product:
bracelets.
3. If visibly soiled, prewash hands and forearms
with plain soap and water or antimicrobial
agent.
5. Rinse hands and forearms under running
water.
6. Dry hands and forearms thoroughly with a
disposable paper towel.
7. Dispense the manufacturer-recommended
amount of the surgical hand rub product.
8. Apply the product to the hands and forearms
instructions.
9. Repeat the product application process as
directed.
10. Rub hands thoroughly until completely dry.
During proper hand hygiene, perioperative personnel
should a) don a surgical mask, b) rinse the hands
from fingertips to elbows, and c) keep surgical attire
dry. What’s Wrong With This Picture? reprinted with
permission from AORN, Inc, Denver, CO. All rights
reserved.
11. In the OR or other invasive procedure room,
don a sterile surgical gown and gloves.1(p66-67)
BENEFITS
Using the four techniques described in the preceding text is the most effective way to prevent and
control infections among patients and health care
workers. Hand hygiene is inexpensive and achieves
a benefit for both populations.1 Hand hygiene reduces the transmission of microorganisms and decreases the incidence of HAIs.3 Evidence supports
that a failure to wash hands appropriately is the
AORN Journal j 455
No 5
leading cause of the spread of multidrug-resistant
organisms among patients.3 Surgical hand antisepsis takes hand hygiene a step beyond hand
washingdit eliminates transient flora from the
hands and reduces resident skin flora.2 Transient
flora are colonized on the superficial layers of the
skin of the hands and are easily removed with
washing, whereas resident skin flora are not only
on the superficial layers but also in the deeper
layers of the skin and are not as easy to remove.2
TIPS & TRICKS
Since 1847, when Ignaz Semmelweis insisted that
students and physicians wash their hands, hand
hygiene has been a challenge to enforce; today is
no different.3 To improve hand hygiene practices,
perioperative nurses first need to understand the
reasons for poor compliance.
Reasons for poor compliance include selfreported factors such as not thinking about it,
forgetting, or skin irritation, as well as aspects such
as a shortage of role models or lack of a safety
culture. Recommended hand hygiene practices may
not always be intuitive. Everyone washes their
hands when they are visibly soiled, bloody, sticky,
or perceived to be dirty. In social situations, people
may touch each other by shaking hands, patting
each other on the back, hugging, or using touch as
affirmation. Hands are not generally washed after
these types of contact. These same types of social
contact can occur in the health care setting among
colleagues and during patient care. Washing the
hands after these types of situations may be overlooked, so what can be done to improve compliance
with hand hygiene by health care workers?
The WHO guideline includes multiple tools to
help with improving hand hygiene practices (eg, the
Global Patient Safety Challenge document, Pilot
Implementation Pack, Hand Hygiene Brochure,
Clean Hands Poster, Hand Hygiene Observation
Survey).2 Additionally, WHO has a hand hygiene
tool kit that provides strategies and tools to those
who are interested in improving compliance with
456 j AORN Journal
SPRUCE
hand hygiene practices at their facilities.6 Some
examples include a facility action plan, protocols
for hand hygiene, and educational materials and
posters. Education is the critical component to improve hand hygiene practices according to WHO.2
The power to inform, along with using other tools,
has been proven to increase compliance.2
Another barrier to following hand hygiene
practices is skin irritation, which can occur with
the use of hand hygiene products. Perioperative
team members should remember to let their hands
dry completely before donning gloves, and in
some cases, alternate products should be provided to personnel who have sensitive or reactive skin.
To determine compliance with hand hygiene
practices, WHO recommends that individual facilities observe health care workers performing hand
hygiene.2 However, no ideal observation method
exists currently.2 Facilities have used direct observations by educated observers as well as automated
observations, such as video cameras to monitor
personnel, with some success; however, direct
observation can be biased, as can the interpretation
of videos. Furthermore, these methods can be
costly and hard to monitor during complex activities.2 It is important for perioperative team members to be examples for each other and remind each
other to perform hand hygiene. For a complete
discussion on observations and other tools, see the
WHO guideline.2
WRAP-UP
The effect of HAIs on patient health and safety and
the economy is significant. The foundation of infection prevention is hand hygiene; therefore,
health care facilities need to make hand hygiene
a number one priority in the prevention of HAIs.
The goals are to refresh perioperative personnel’s
knowledge of hand hygiene and instill a new sense
of urgency to protect patients and health care
workers from the potential of developing an
infection and spreading it to others.
References
1. Recommended practices for hand hygiene. In: Perioperative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2013:63-74.
2. WHO Guidelines on Hand Hygiene in Health Care.
Geneva, Switzerland: World Health Organization; 2009.
http://whqlibdoc.who.int/publications/2009/9789241597906_
eng.pdf. Accessed September 9, 2013.
3. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. MMWR Recomm Rep.
2002;51(RR-16):1-45.
4. How to Handwash? [poster]. Geneva, Switzerland: World
Health Organization; 2009. http://www.who.int/gpsc/5may/
How_To_HandWash_Poster.pdf. Accessed September 13,
2013.
5. How to Handrub? [poster]. Geneva, Switzerland: World
www.aornjournal.org
How_To_HandRub_Poster.pdf. Accessed September 13,
2013.
6. Guide to Implementation: A Guide to the Implementation
of the WHO Multimodal Hand Hygiene Improvement
Strategy. Geneva, Switzerland: World Health Organization; 2009. http://whqlibdoc.who.int/hq/2009/WHO_IER_
PSP_2009.02_eng.pdf. Accessed September 9, 2013.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,
CNOR, is the director, Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr
Spruce has no declared affiliation that could be
perceived as posing a potential conflict of interest in the publication of this article.
Check back in January 2014 for the next “Back to Basics” topic: Hygiene and Cleanliness.
AORN Journal j 457
EXAMINATION
1.2
CONTINUING EDUCATION PROGRAM
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge of best practices related to hand hygiene
and performing surgical hand antisepsis.
OBJECTIVES
2. Discuss best practices that could enhance safety in the perioperative area.
3. Describe implementation of evidence-based practice in relation to perioperative
nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1.
2.
5.
Hand hygiene practices can
1. decrease microorganism transmission to patients and health care workers.
2. jeopardize safety in the perioperative area if
not performed correctly.
3. significantly improve the burden on the
global health care system if performed as
recommended.
a. 1 and 3
b. 1 and 2
c. 2 and 3
d. 1, 2, and 3
According to the World Health Organization,
agents used for surgical hand preparation should
1. be fast-acting and persistent.
2. contain a nonirritating antimicrobial preparation.
3. be chlorine based to kill spores.
4. have broad-spectrum activity.
458 j AORN Journal
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No 5
significantly reduce microorganisms on intact
skin.
a. 1 and 2
b. 1 and 3
c. 1, 2, 4, and 5
d. 1, 2, 3, 4, and 5
3.
According to AORN, hand hygiene should be
performed
1. after removing personal protective equipment.
2. before and after every patient contact.
3. on arrival and before leaving the facility.
4. when hands are visibly soiled.
a. 1 and 3
b. 2 and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4
4.
Evidence shows that a failure to wash hands appropriately is the leading cause of the spread of
multidrug-resistant organisms among patients.
a. true
b. false
! AORN, Inc, 2013
CE EXAMINATION
5.
Strategies that can be used to improve compliance
with hand hygiene protocols include
1. creating and implementing a facility action plan.
2. establishing protocols for hand hygiene.
3. mandating one brand of hand hygiene products
for all personnel to use.
www.aornjournal.org
4.
5.
monitoring hand hygiene practices and reporting on findings to personnel.
providing personnel with educational materials.
a. 2 and 4
b. 1, 2, 4, and 5
c. 1, 3, 4, and 5
d. 1, 2, 3, 4, and 5
AORN Journal j 459
LEARNER EVALUATION
1.2
T
his evaluation is used to determine the extent
to which this continuing education program
met your learning needs. Rate the items as
described below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss common areas of concern that relate to
perioperative best practices.
Low 1. 2. 3. 4. 5. High
2. Discuss best practices that could enhance safety in
the perioperative area.
Low 1. 2. 3. 4. 5. High
3. Describe implementation of evidence-based practice
in relation to perioperative nursing care.
Low 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
5. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
7. Will you change your practice as a result of reading
this article? (If yes, answer question #7A. If no,
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Journal of Microbiology, Immunology and Infection (2015) 48, 322e328
ScienceDirect
journal homepage: www.e-jmii.com
ORIGINAL ARTICLE
Comparative antimicrobial efficacy of
alcohol-based hand rub and conventional
surgical scrub in a medical center
Ni-Jiin Shen a, Sung-Ching Pan a,b, Wang-Huei Sheng a,b,*,
Kwei-Lian Tien b, Mei-Ling Chen b, Shan-Chwen Chang b,c,
Yee-Chun Chen a,b,c
a
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan
c
Department of Medicine, National Taiwan University, College of Medicine, Taipei, Taiwan
b
Received 29 April 2013; received in revised form 30 July 2013; accepted 13 August 2013
Available online 21 September 2013
KEYWORDS
Alcohol-based hand
rub;
Surgical antisepsis;
Surgical site infection
Background: Hand hygiene is the cornerstone of aseptic techniques to reduce surgical site
infection. Conventional surgical scrub is effective for disinfecting a surgeon’s hands. However,
the compliance of conventional scrub may be hindered by skin damage, allergy, and time.
Alcohol-based hand rub has a satisfactory antimicrobial effect, but mostly in laboratory settings. Our aim was to compare a conventional surgical scrub with an alcohol-based hand rub
to evaluate antimicrobial efficacy.
Methods: From June 1, 2010 to July 31, 2011, 128 healthcare workers were enrolled in the
study. They used an alcohol-based hand rub or a conventional surgical scrub as preoperative
hand antisepsis during their routine practice. Hand sampling for cultures were performed
before and after operations. Positive culture plates were further processed for pathogen identification.
Results: The culture positive rate of the alcohol-based hand rub was 6.2% before operations
and 10.8% after operations. Both rates were lower than the conventional surgical scrub
[47.6% before operations (p < 0.001) and 25.4% after operations (p Z 0.03)]. The most identified pathogens were Gram-positive with coagulase-negative staphylococci being the major
pathogen. Multivariate analysis showed that prior hand condition (p Z 0.21) and type of surgery such as cardiovascular surgery (p Z 0.12) were less relevant, but the alcohol-based hand
rub was a significant protective factor for positive hand cultures.
* Corresponding author. Department of Internal Medicine, National Taiwan University Hospital, Number 7, Chung-Shan South Road, Taipei
100, Taiwan.
E-mail address: [email protected] (W.-H. Sheng).
1684-1182/$36 Copyright ª 2013, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jmii.2013.08.005
323
Conclusion: The alcohol-based hand rub was more efficacious for surgical antisepsis and had
sustained efficacy, compared to conventional surgical scrub. We suggest that alcohol-based
hand rubs could be an alternative surgical antiseptic in the operative theater.
Copyright ª 2013, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights
reserved.
Introduction
Surgical site infection is a globally recognized problem that
results in significant morbidity.1 Joseph Lister was among
the first to demonstrate the effect of skin disinfection on
reducing surgical site infections.2 Thus, washing hands with
antimicrobial soaps, warm water, and frequently with a
brush became the primary protocol for surgical hand
preparation. Antiseptic soaps should rapidly eliminate
transient skin flora and reduce resident flora on the hands
to a minimum during a surgical procedure, and thus lower
the risk of surgical site contamination if surgical gloves are
perforated or torn during surgery.3
Conventional surgical hand antisepsis consists of an
aqueous scrub with a brush by using povidone iodine (PVP-I)
or chlorhexidine-based detergents. However, scrubbing
with these detergents strips skin oils, compromises skin
integrity, and (if a brush is used) often causes microabrasions, thereby increasing the risk of subsequent colonization by pathogens.4 As a result, conventional surgical
scrub has the disadvantages of skin damage and allergic
skin reaction. It is also time consuming to use them. In the
laboratory setting, an alcohol-based hand rub is as effective as conventional surgical scrub in its antimicrobial
ability.5,6 In addition, skin irritation or dermatitis happened
less frequently with an alcohol-based hand rub in a small
series of case studies. This can also help increase the
compliance of hand washing by healthcare providers in
hospitals.7e9
Several alcohol-based hand rubs have been licensed for
the commercial market, although there are few clinical
studies to compare the antisepsis efficacy against conventional surgical scrub in a routine operating practice environment.10,11 The World Health Organization (WHO)
guidelines also state that surgical antisepsis is a state of
art, suggesting that there are no optimal antiseptics.12 We
conducted a prospective, observational study in our hospital with the aim of comparing a conventional surgical
scrub with an alcohol-based hand rub to evaluate their
antisepsis efficacy before and after operations.
Materials and methods
Hospital setting
The National Taiwan University Hospital (NTUH) is a medical
center with 2388 beds. It comprises three operation theaters
with 52 functioning operating rooms (including five delivery
rooms). More than 140 surgical procedures were performed
daily during 2010 and 2011. The entrance of each operating
room is equipped with a sensor sink or a step-operated sink
that contains two sets of antisepsis scrubbing facilities. The
study was approved by the surgical committee and by the
institutional review board of the National Taiwan University
Hospital (NTUH-IRB; No. 201109015RC).
Inclusion criteria
This prospective observational study was conducted from
June 1, 2010 to July 31, 2011. The volunteer participants
were practicing doctors and nurses who had previous
experience with the conventional surgical scrub protocol in
the operating environment. They were allocated to the
intervention group (i.e., alcohol-based hand rub) or the
control group (i.e., conventional surgical scrub), based on
their choice (rather than by randomization). All participants were educated and rehearsed in the alcohol-based
hand rub protocol prior to this study. The participants’
characteristics such as having an allergy to conventional
surgical scrub or having wounds on their hands and the
characteristics of the surgeries such as surgical specialty,
surgical site, surgical wound classification, type of surgery,
blood loss amount, operation duration, and glove wearing
duration were recorded.
Exclusion criteria
Participants were excluded if they did not complete
providing samples for culture before the operation (T0) and
after the operation (T1). Participants with missing baseline
characteristics data were also excluded.
Hand preparation and sampling
The alcohol-based hand rub contained 1% chlorhexidine
gluconate and 61% ethyl alcohol (Avagard; 3M, MN, USA).
The standard hand rub protocol was as follows: (1) one
pump (2 mL) of lotion was dispensed into the palm of the
left hand; (2) the fingertips of the right hand were dipped
into the lotion to decontaminate under the nails; (3) the
remaining lotion was spread over the right hand and up to
just above the elbow; and (4) a second pump (2 mL) of
lotion was then placed into the palm of the right hand. This
process was repeated by dipping the fingers tip of the left
hand into the lotion, followed by spreading it over the left
hand and up to just below the elbow. Another 2 mL of lotion
was finally placed into cupped hands and reapplied to all
aspects of the hands up to the wrists. This solution was then
allowed to dry. The three-step application of the alcoholbased hand rub (Avagard) was completed within 2 minutes.
The conventional surgical scrub contained 4% chlorhexidine gluconate (Hibiscrub; Janson’s Medical Co., Taipei,
324
N.-J. Shen et al.
Taiwan) or 7.5% povidone-iodine. The standard conventional surgical scrub protocol was as follows: (1) three full
squirts (6 mL) of PVP-I or chlorhexidine were placed into
the cupped hands; (2) this was followed by a five-minute
hand scrubbing just up to the elbow by using a sterile scrub
brush; and (3) the lotion was rinsed away by tap water. All
aforementioned steps were repeated, except the hands
were dried with sterile towels, instead of being rinsed with
tap water, to avoid recontamination.
After hand scrubbing or rubbing protocol, every participant was sampled immediately before the operation (T0).
They then performed the scheduled operations. Another
sample was obtained after the operation (T1). We used
normal saline-moistened sterile cotton swabs to obtain
Table 1
specimens for cultures by wiping through every part of the
hand (including the ventral and dorsal side of the hands),
the fingertips, and the lateral sides of the fingers and the
wrists. The samples were immediately inoculated onto 5%
sheep blood agar plates.
Microbiology
The causative pathogens were identified with conventional
methods in accordance with the Clinical Laboratory Standard Institute (CLSI) guidelines.13 The 5% sheep blood agar
culture plates were maintained at 37! C until sufficient
growth had occurred. The plates were subsequently read by
a bacteriologist who was blinded to the method of
Baseline characteristics of participants in the alcohol-based hand rub and the conventional surgical scrub groups
Healthcare workers
Attending physician
Residents
Interns
Nurses
Have both allergy to povidone-iodine and
presence of wounds on hand
Surgeon specialty
General surgery
Chest surgery
Plastic surgery
Neurosurgery
Orthopedic surgery
Urologic surgery
Surgical site
Head
Chest
Abdomen
Pelvis
Spine
Extremities
Clean
Clean-contaminated
Contaminated
Type of surgery
Emergency
Elective
Blood loss amount, median (mL)
Blood loss amount > 300 mL
Surgery duration, median (min)
Gloves wearing duration, median (min)
Attending physician
Resident physician
Intern
Operating room nurse
Total
Alcohol-based
hand rub
Conventional surgical
scrub
128
22
52
9
45
15
23
10
65
13
24
3
25
12
10
8
63
9
28
6
20
3
13
2
0.392
0.386
0.320
0.426
0.025
0.439
0.096
40
16
17
11
9
13
3
6
13
21
7
10
4
0
7
2
6
8
19
9
7
7
9
6
1
0
5
0.793
0.548
0.476
0.360
0.001
0.816
0.999
0.028
0.413
25
28
34
20
4
17
9
8
18
14
0
16
16
20
16
6
4
1
0.099
0.008
0.769
0.061
0.056
<0.001
81
45
2
48
15
2
33
30
0
0.012
0.004
0.496
0.016
2
63
10 (10e80)
9
70 (35e160)
80 (42e151)
66 (37e103)
79 (40e159)
103 (90e119)
90 (48e165)
10
53
20 (10e400)
16
140 (43e241)
105 (47e181)
135 (66e162)
105 (44e252)
59 (32e211)
113 (72e172)
12
116
10 (10e237.5)
25
105 (40e241)
96 (42e164)
84 (45e152)
100 (42e198)
77 (41e163)
102 (53e165)
p
0.036
0.099
0.071
0.072
0.102
0.174
0.439
0.392
Table 2
325
Comparison of the sample cultures and the identified pathogens before and after the operation
Positive rate (T0)
Identified pathogens
Gram-positive
Coagulase-negative
staphylococci
Bacillus
Staphylococcus aureus
Gram-positive bacilli
Micrococcus spp.
Corynebacterium spp.
Gram-negative
Rosemonas spp.
Acinetobacter baumannii
Moraxella spp.
Pseudomonas aeruginosa
Klebsiella oxytoca
Sphingomonas paucimobilis
Multi-pathogens
Alcohol-based
hand rub
% (n/N )
Conventional
surgical scrub
% (n/N )
p
Alcohol-based
hand rub
% (n/N )
6.15 (4/65)
47.62 (30/63)
<0.001
10.77 (7/65)
25.4 (16/63)
0.031
6.15 (4/65)
1.54 (1/65)
42.86 (28/63)
42.86 (27/63)
<0.001
<0.001
1.54 (6/65)
6.15 (4/65)
23.81 (15/63)
14.29 (9/63)
0.026
0.152
1.54 (1/65)
3.17 (2/63)
0.616
1.54 (1/65)
1.54 (1/65)
0
3.17 (2/63)
0.999
0.616
1.54 (1/65)
0
3.17 (2/63)
1.59 (1/63)
0.616
0.492
1.54 (1/65)
1.54 (1/65)
0
0
0
1.54 (1/65)
1.59
3.17
1.59
3.17
1.59
3.17
(1/63)
(2/63)
(1/63)
(2/63)
(1/63)
(2/63)
0.999
0.616
0.492
0.24
0.492
0.616
0
0
1.59 (1/63)
1.59 (1/63)
0.492
0.492
3.17 (2/63)
0.999
0.24
0
1.54 (1/65)
1.59 (1/63)
0
0.492
0.999
1.54 (1/65)
4.76 (3/63)
0.361
1.54 (1/65)
0
Conventional
surgical scrub
% (n/N )
0
p
T0 Z before surgery; T1 Z after surgery.
antisepsis. The positive culture plates were further processed with standard biochemical methods to identify the
pathogens.
Statistical analysis
Data were analyzed by using the PASW Statistics version 18
software (SPSS Inc., Chicago, IL, USA). Proportion comparisons for categorical variables were performed by using Chisquare test. Fisher’s exact test was used when data were
sparse. Statistical significance was set at p < 0.05. Variants
with p < 0.05 or with clinical importance were further
taken into multivariate logistic regression model analysis by
using the backward selection to predict the protective
factors for positive sample cultures.
and 30.16% (control group); p Z 0.793; Table 1]. The
alcohol-based hand rub group was involved in more orthopedic surgeries than the conventional surgical scrub group
(p Z 0.002) and the conventional surgical scrub group was
involved in more neurologic surgeries than the interventional group (p Z 0.014). There was a significant difference
in the skin condition between the two groups for an allergic
reaction to the povidone-iodine scrub (p Z 0.016). The
median blood loss amount was 10 mL in the interventional
group and 20 mL in the control group (p Z 0.036). The
median surgery duration was 70 minutes in the interventional group and 140 minutes in the control group
(p Z 0.071). The median glove wearing duration was 80
minutes in the interventional group and 105 minutes in the
control group (p Z 0.072; Table 1). Of the sample cultures
Results
During the study period, 154 healthcare providers were
invited. Twenty-six participants were excluded because of
not providing sample cultures after completing surgeries.
Therefore, 128 healthcare providers were enrolled for
analysisd65 participants were in the interventional group
and 63 participants were in the control group. In the
interventional group, there were 13 attending physicians,
24 residents, 3 interns, and 25 operating room nurses. In
the control group, there were 9 attending physicians, 28
residents, 6 interns, and 20 operating room nurses. There
were no significant differences in demographic characteristics between these two groups. However, surgical specialty was a variant, and most people in both groups were
involved in general surgery [32.31% (interventional group)
Figure 1. Positive rate of sample cultures obtained before
the operation and after the operation for alcohol-based hand
scrub and conventional surgical scrub groups.
326
N.-J. Shen et al.
interventional group were positive and 16 (25.40%) cultures
in the control group were positive with a clinically significant difference (p Z 0.031). In both groups, Gram-positive
pathogens comprised most of the identified pathogens.
There was no significant difference for other identified
pathogens (Table 2).
obtained before the operations (T0), four (6.15%) cultures
in the interventional group were positive and 30 (47.62%)
cultures in the control group were positive with a clinically
significant difference (p < 0.001). Most identified pathogens were Gram positive. Of the cultures sampled after
the operations (T1), seven (10.77%) cultures in the
Table 3
cultures
Risk factors for positive sample cultures by using multivariate regression analysis for the prediction of positive
Type of surgical hand antisepsis
Conventional surgical scrub
Sampling time
Healthcare workers
Attending physician
Residents
Interns
Nurses
Have both allergy to povidone-iodine
and presence of wounds on hand
Surgery specialty
General surgery
Chest surgery
Plastic surgery
Neurologic surgery
Orthopedic surgery
Urologic surgery
Surgical site
Head
Chest
Abdomen
Pelvis
Spine
Extremities
Clean
Clean-contaminated
Contaminated
Type of surgery
Emergent operation
Elective
Blood loss amount (mL)
Surgery duration (min)
Gloves wearing duration (min)
Attending physician
Residents
Interns
Nurses
Positive culture
(n Z 57)
Negative culture
(n Z 199)
Univariate analysis
p
Multivariate analysis
p
11
46
119
80
<0.001
<0.001
34
23
94
105
0.098
13
22
0
22
7
16
7
31
82
18
68
23
30
13
0.202
0.724
0.016
0.537
0.881
0.024
0.154
21
5
3
4
6
10
1
1
6
59
27
31
18
12
16
5
11
20
0.302
0.334
0.047
0.792
0.242
0.036
0.999
0.31
0.916
18
9
18
8
1
3
32
47
50
32
7
31
0.009
0.207
0.331
0.708
0.689
0.047
27
28
2
135
62
2
0.005
0.012
0.215
0.555
0.636
8
49
10 (10e200)
96 (40e238)
88 (47e154)
105 (66e151)
48 (40e141)
0
123 (67e178)
16
183
10 (10e250)
108 (40e241)
96 (45e170)
78 (40e153)
105 (42e206)
77 (44e148)
95 (48e160)
0.171
0.915
Data are presented as n or median (range).
NA Z non-applicable; T0 Z before surgery; T1 Z after surgery.
0.908
0.935
0.8
0.52
0.152
NA
0.31
0.998
0.543
0.210
0.119
0.499
0.726
0.463
The culture positive rate was higher in the control group
at T0 and at T1 (Fig. 1). We found a trend that the culturepositive rate of the interventional group increased from T0
to T1, whereas the trend of the control group declined from
T0 to T1.
For outcome analysis, 256 sample cultures were further
stratified according to culture results. We had 57 positive
sample cultures and 199 negative sample cultures. Most
sample cultures in the interventional arm had negative results with a significant difference (p < 0.001). All sample
cultures of the interns had negative results (p Z 0.019). We
also found that participants who were involved in cardiovascular surgeries had more negative sample cultures
(p Z 0.043), whereas participants who were involved in earnose-throat surgeries had more positive sample cultures
(p Z 0.036). The participants were more likely to have
positive sample cultures when they operated over the patient’s head (p Z 0.009), were involved in surgeries with
clean-contaminated wounds (p Z 0.012), or had wounds on
their hands (p Z 0.024). By contrast, participants were more
likely to have negative sample cultures when they operated
over a patient’s extremities (p Z 0.043) or were involved in
surgeries with clean wounds (p Z 0.005; Table 3). We used
variants with p < 0.05 or with clinical importance into
multivariate regression model analysis. Only the alcoholbased hand rub was a protective factor in the positive sample cultures (p < 0.001). Table 3 summarizes the results.
Discussion
In this prospective observational study, we found that the
two-minute three-step alcohol-based hand rub had a lower
culture positive rate before and after the operations. Our
results suggest that the alcohol-based hand rub is efficient
and less time consuming.
The increasing use of alcohol-based hand rubs has led to
trials studying its efficacy as an alternative to traditional hand
scrubbing for hand antisepsis. Olson et al14 conducted a prospective, randomized in vivo study and found that an alcoholbased hand rub was not inferior to alcohol-only products at all
sampling points. Burch et al10 compared the efficacy of an
alcohol-based hand rub to the traditional 4% chlorhexidine
scrub in a cardiac operating room environment. The alcoholbased hand rub showed no difference in comparison to the
traditional scrub. A larger study conducted by Weight et al15
evaluated the use of an alcohol-based hand rub or conventional surgical scrub as surgical antisepsis in 3600 pediatric
urological operations. The surgical site infection rates between the two groups were similar [2 of 1800 (alcohol-based
rub) procedures vs. 3 of 1800 procedures (conventional
scrub); p > 0.99]. The insignificant difference may have
resulted from the relatively low incidence of surgical site infections. A large sample size is needed to statistically reveal
the difference between the two types of hand rub.
Another reason for the insignificant difference may be that
a different measurement method was used. Larson et al16
focused on different bacterial colony-forming units,
whereas our study focused on a positive culture rate and on
identifying a specific pathogen. By contrast, our study chose
an intermediate end point (i.e., the positive rate of the hand
culture), which effectively revealed a significantly lower risk
327
of hand contamination before and after using an alcoholbased hand rub than after using a conventional PVP-I-based
or chlorhexidine-based hand rub. In addition, our study
involved the most common surgery specialties in the clinical
setting, instead of being limited to a specific surgical
department; this increased the generalizability of the study
results. The positive culture rate of our study was therefore
significantly lower with the alcohol-based hand rub. Between
the two different hand rub regimens, there was also no difference in the culture rate of highly pathogenic pathogens
(e.g., Staphylococcus aureus or Pseudomonas aeruginosa).
To date, few studies have evaluated the sustained effect
of alcohol-based hand rubs. Mulberry et al17 conducted two
randomized, blinded, well-controlled clinical studies
involving 137 healthy study participants and proved that the
antimicrobial effect of an alcohol-based hand rub could
persist more than 3 hours. Choi18 compared an alcohol-based
hand rub against a traditional 7.5% PVP-I scrub and found the
alcohol-based hand rub had a lower positive culture rate
after operations, compared to the traditional scrub.
In our study, the positive rate was higher after operations than before operations in the alcohol-based hand rub
group. This indicates that the sustained antimicrobial effect of the alcohol-based hand rub may be insufficient.
Our study has several limitations. First, our prospective
study was a nonrandomized cohort that used volunteer
participants. We also excluded volunteers who did not have
postoperative microbial surveillance. However, we adapted
a standardized sampling method and the microbiology results were observed by a microbiologist who was blinded to
the antiseptic regimens. In this way, we could reduce selection bias to a minimum. Second, the average operation
duration in our study was relatively short (median time, 1.5
hours). As a result, the data should be generalized with
caution for operations of longer duration. Third, our case
number was small. Large randomized studies on operations
with longer durations are furthermore needed.
In conclusion, our results showed that an alcohol-based
hand rub was more efficacious than a conventional surgical
scrub for surgical antisepsis with sustained efficacy. The
rapid bactericidal effect also suggested that an alcoholbased hand rub could be an alternative surgical antiseptic
in the operative theaters.
Conflict of interest
All authors declare that there is no conflict of interest.
Acknowledgments
We are grateful to the members of the operating theaters
for participating in this study.
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Weight CJ, Lee MC, Palmer JS. Avagard hand antisepsis vs.
traditional scrub in 3600 pediatric urologic procedures. Urology 2010;76:15e7.
Larson EL, Aiello AE, Heilman JM, Lyle CT, Cronquist A,
Stahl JB, et al. Comparison of different regimens for surgical
hand preparation. AORN J 2001;73:412e4.
Mulberrry G, Snyder AT, Heilman J, Pyrek J, Stahl J. Evaluation
of a waterless, scrubless chlorhexidine gluconate/ethanol
surgical scrub for antimicrobial efficacy. Am J Infect Control
2001;29:377e82.
Choi JS. Evaluation of a waterless, scrubless chlorhexidine
gluconate/ethanol surgical scrub and povidone-iodine for
antimicrobial efficacy. Taehan Kanho Hakhoe Chi 2008;38:
39e44.
CONTINUING EDUCATION
Back to Basics: Hand
Hygiene and Surgical Hand
Antisepsis
1.2
www.aorn.org/CE
Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours
are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Event: #13533
Session: #0001
Fee: Members $7.20, Nonmembers $14.40
Dr Spruce has no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication of this
article.
The behavioral objectives for this program were created by
Kimberly Retzlaff, managing editor, with consultation from
Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan
Bakewell, MS, RN-BC, director, Perioperative Education. Ms
Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of
interest in the publication of this article.
The CE contact hours for this article expire November 30,
2016. Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge of best practices related
to hand hygiene and performing surgical hand antisepsis.
Conflict of Interest Disclosures
Objectives
2. Discuss best practices that could enhance safety in the
perioperative area.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
Accreditation
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses
Credentialing Center approves or endorses products mentioned
in the activity.
! AORN, Inc, 2013
November 2013
Vol 98 No 5 !
AORN Journal j 449
1.2
www.aorn.org/CE
ABSTRACT
Health careeassociated infections (HAIs) are a significant issue in the United
States and throughout the world, but following proper hand hygiene practices is the
most effective and least expensive way to prevent HAIs. Hand hygiene is inexpensive and protects patients and health care personnel alike. The four general
types of hand hygiene that should be performed in the perioperative environment
are washing hands that are visibly soiled, hand hygiene using alcohol-based
products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based
surgical hand rub product. Barriers to proper hand hygiene may include not
thinking about it, forgetting, skin irritation, a lack of role models, or a lack of a
safety culture. One strategy for improving hand hygiene practices is monitoring
hand hygiene as part of a quality improvement project, but the most important
aspect for perioperative team members is to set an example for other team members
by following proper hand hygiene practices and reminding each other to perform
hand hygiene. AORN J 98 (November 2013) 450-457. ! AORN, Inc, 2013. http://
dx.doi.org/10.1016/j.aorn.2013.08.017
Key words: hand hygiene, surgical hand rub, surgical hand scrub, health caree
associated infection.
I
t is appropriate to begin this “Back to Basics”
series with hand hygiene and surgical hand
antisepsis, because these activities are the foundation of infection prevention for all perioperative
personnel. It is probably safe to say that anyone in
health care today has heard of the importance of
hand hygiene. Hand hygiene is the most effective
and least expensive way to prevent health caree
associated infections (HAIs).1 All health care
workers can prevent HAIs by washing their hands.
Health careeassociated infections are a major
problem in the United States and throughout the
world. In US hospitals, the most frequently occurring HAIs are urinary tract infections (36%),
surgical site infections (20%), and blood stream
infections and pneumonia (11%).2 The economic
effect of these infections was $6.5 billion in 20042
and reached $33.8 billion in 2009.3 Hand hygiene
practices can jeopardize safety in the perioperative
area if not performed as recommended; if performed correctly, hand hygiene can significantly improve the burden on the global health care system
by decreasing microorganism transmission to patients and health care workers.
HOW-TO GUIDE
The World Health Organization (WHO) Guidelines
on Hand Hygiene in Health Care state,
450 j AORN Journal
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! AORN, Inc, 2013
Guidelines in the [United States] recommend
that agents used for surgical hand preparation
should significantly reduce microorganisms on
intact skin, contain a non-irritating antimicrobial preparation, have broad-spectrum activity,
and be fast-acting and persistent.2(p55)
A complete guide to products is included in the
WHO guidelines. However, there are basic types
of products that should be used in perioperative
settings. Alcohol-based hand rubs are the preferred type of product for hand hygiene, while
the recommended formulation for surgical hand
antisepsis products is more complex and there
are multiple antiseptic agents that fit this
category.2
The AORN “Recommended practices for hand
hygiene”1 recommends that hand hygiene should
be performed at numerous times:
n
n
n
n
n
n
n
n
n
n
www.aornjournal.org
should be performed in the perioperative environment: washing hands that are visibly soiled, hand
hygiene using alcohol-based products, surgical
hand scrubs, and surgical hand scrubs using an
alcohol-based surgical hand rub product. There
are specific techniques for each of these types of
hand hygiene.
Washing Hands That Are Visibly Soiled
This type of hand hygiene should take 40 to 60
seconds to perform. According to WHO,2 health
care personnel should use the following 11-step
hand-washing process to ensure their hands are
properly cleaned (Figure 1). After wetting hands
with water, the following steps should be taken:
1. Apply enough soap to cover all hand surfaces;
interlocked;
on arrival at the facility,
before and after every patient contact,
before putting on gloves,
after removing gloves,
after removing personal protective equipment,
after possible contact with blood or other potentially infectious
materials,
before and after eating,
Resources for Hand Hygiene
before and after using the
Videos
restroom,
n Hygi!
ene des mains H^opitaux Universitaires de Gen!eve Vigi
before leaving the
Germe. http://youtu.be/0at_jtzJCDM.
facility, and
n WHO hand hygiene video. http://youtu.be/s08yiZBSGOw.
when hands are visibly
soiled.
Perioperative personnel
should review and be mindful
of these recommended practices and keep reminders of
them visible in a prominent
place to help ensure that
good practices become habit.
There are four general
types of hand hygiene that
Online resources
n Clean care is safer care. World Health Organization. http://
www.who.int/gpsc/5may/background/5moments/en.
n Hand hygiene in healthcare settings. Centers for Disease Control
and Prevention. http://www.cdc.gov/handhygiene/Resources
.html#HCP.
n How to wash your hands e hand washing techniques from the
NHS. NHS. http://www.wash-hands.com/resources.
Web site access verified August 12, 2013.
AORN Journal j 451
No 5
SPRUCE
Figure 1. How to Handwash. http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf ª World Health
452 j AORN Journal
and vice versa;
8. Rinse hands with water;
9. Dry hands thoroughly with a single use towel;
10. Use towel to turn off faucet;
11. Your hands are now safe.4
Hand Hygiene Using Alcohol-Based
Products
During situations in which hands are not visibly
soiled, such as after removing gloves or touching
a doorknob, perioperative team members should
use an alcohol-based hand rub for hand hygiene.
This type of hand hygiene process should take 20 to
30 seconds to complete. According to WHO, 2
perioperative team members should use an eightstep hand-rub process to ensure their hands are
properly cleaned (Figure 2). If visibly soiled,
hands and forearms should be prewashed with
plain soap and water or an antimicrobial agent,
and then the following steps should be taken:
1. Apply a palmful of the product in a cupped
hand, covering all surfaces;
interlocked;
and vice versa;
8. Once dry, your hands are safe.5
Surgical Hand Scrub
According to AORN,1 a surgical hand scrub should
be performed before donning sterile gloves for
surgical or other invasive procedures. This process is effective at a duration of three to five minutes. Perioperative team members should use the
www.aornjournal.org
following steps to ensure their hands are properly cleaned:
bracelets.
3. Wash hands and forearms if visibly soiled with
soap and running water immediately before
beginning the surgical scrub.
Discard the nail cleaner in the appropriate
container.
5. Rinse hands and forearms under running water.
6. Dispense the approved antimicrobial scrub
agent according to the manufacturer’s written
directions.
7. Apply the antimicrobial agent to wet hands and
forearms using a soft, nonabrasive sponge.
8. A three- or five-minute scrub should be timed
to allow adequate product contact with skin,
directions.
9. Visualize each finger, hand, and arm as having
four sides. Wash all four sides and the web
space, keeping the hand elevated. Repeat this
process for opposite fingers, hand, and arm.
10. For water conservation, turn water off when it
is not directly in use, if possible.
11. Avoid splashing surgical attire.
12. Discard sponges, if used, in appropriate
containers.
13. Hands and arms should be rinsed under running water in one direction from fingertips to
elbows as often as needed.
14. Hold hands higher than elbows and away from
surgical attire.
15. In the OR, beginning at the fingertips of one
hand and working up to the elbow with one end
of the towel and repeating the process with the
clean end of the towel on the other hand and
arm before discarding the towel and donning
a sterile surgical gown and gloves.1(p67)
AORN Journal j 453
No 5
SPRUCE
Figure 2. How to Handrub. http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf ª World Health
454 j AORN Journal
www.aornjournal.org
Surgical Hand Scrub Using an AlcoholBased Surgical Hand Rub Product
According to AORN,1 an alcohol-based antiseptic
surgical hand rub with documented persistent and
cumulative activity that has met US Food and Drug
Administration regulatory requirements is acceptable. The WHO does not recommend a standardized process for the surgical hand scrub with an
alcohol-based product; however, the organization
does stress the importance of keeping the hands wet
with the product throughout the process.2 The
volume of product that should be used depends on
the size of the team member’s hands and forearms.
After the product is dispensed, the forearms should
be the focus of the rub for the first minute and then
the hands should be the focus, following the same
procedure outlined in the hand scrub technique. To
ensure their hands are properly cleaned, perioperative team members should use the following steps
during a surgical hand scrub using an alcohol-based
surgical hand rub product:
bracelets.
3. If visibly soiled, prewash hands and forearms
with plain soap and water or antimicrobial
agent.
5. Rinse hands and forearms under running
water.
6. Dry hands and forearms thoroughly with a
disposable paper towel.
7. Dispense the manufacturer-recommended
amount of the surgical hand rub product.
8. Apply the product to the hands and forearms
instructions.
9. Repeat the product application process as
directed.
10. Rub hands thoroughly until completely dry.
During proper hand hygiene, perioperative personnel
should a) don a surgical mask, b) rinse the hands
from fingertips to elbows, and c) keep surgical attire
dry. What’s Wrong With This Picture? reprinted with
permission from AORN, Inc, Denver, CO. All rights
reserved.
11. In the OR or other invasive procedure room,
don a sterile surgical gown and gloves.1(p66-67)
BENEFITS
Using the four techniques described in the preceding text is the most effective way to prevent and
control infections among patients and health care
workers. Hand hygiene is inexpensive and achieves
a benefit for both populations.1 Hand hygiene reduces the transmission of microorganisms and decreases the incidence of HAIs.3 Evidence supports
that a failure to wash hands appropriately is the
AORN Journal j 455
No 5
leading cause of the spread of multidrug-resistant
organisms among patients.3 Surgical hand antisepsis takes hand hygiene a step beyond hand
washingdit eliminates transient flora from the
hands and reduces resident skin flora.2 Transient
flora are colonized on the superficial layers of the
skin of the hands and are easily removed with
washing, whereas resident skin flora are not only
on the superficial layers but also in the deeper
layers of the skin and are not as easy to remove.2
TIPS & TRICKS
Since 1847, when Ignaz Semmelweis insisted that
students and physicians wash their hands, hand
hygiene has been a challenge to enforce; today is
no different.3 To improve hand hygiene practices,
perioperative nurses first need to understand the
reasons for poor compliance.
Reasons for poor compliance include selfreported factors such as not thinking about it,
forgetting, or skin irritation, as well as aspects such
as a shortage of role models or lack of a safety
culture. Recommended hand hygiene practices may
not always be intuitive. Everyone washes their
hands when they are visibly soiled, bloody, sticky,
or perceived to be dirty. In social situations, people
may touch each other by shaking hands, patting
each other on the back, hugging, or using touch as
affirmation. Hands are not generally washed after
these types of contact. These same types of social
contact can occur in the health care setting among
colleagues and during patient care. Washing the
hands after these types of situations may be overlooked, so what can be done to improve compliance
with hand hygiene by health care workers?
The WHO guideline includes multiple tools to
help with improving hand hygiene practices (eg, the
Global Patient Safety Challenge document, Pilot
Implementation Pack, Hand Hygiene Brochure,
Clean Hands Poster, Hand Hygiene Observation
Survey).2 Additionally, WHO has a hand hygiene
tool kit that provides strategies and tools to those
who are interested in improving compliance with
456 j AORN Journal
SPRUCE
hand hygiene practices at their facilities.6 Some
examples include a facility action plan, protocols
for hand hygiene, and educational materials and
posters. Education is the critical component to improve hand hygiene practices according to WHO.2
The power to inform, along with using other tools,
has been proven to increase compliance.2
Another barrier to following hand hygiene
practices is skin irritation, which can occur with
the use of hand hygiene products. Perioperative
team members should remember to let their hands
dry completely before donning gloves, and in
some cases, alternate products should be provided to personnel who have sensitive or reactive skin.
To determine compliance with hand hygiene
practices, WHO recommends that individual facilities observe health care workers performing hand
hygiene.2 However, no ideal observation method
exists currently.2 Facilities have used direct observations by educated observers as well as automated
observations, such as video cameras to monitor
personnel, with some success; however, direct
observation can be biased, as can the interpretation
of videos. Furthermore, these methods can be
costly and hard to monitor during complex activities.2 It is important for perioperative team members to be examples for each other and remind each
other to perform hand hygiene. For a complete
discussion on observations and other tools, see the
WHO guideline.2
WRAP-UP
The effect of HAIs on patient health and safety and
the economy is significant. The foundation of infection prevention is hand hygiene; therefore,
health care facilities need to make hand hygiene
a number one priority in the prevention of HAIs.
The goals are to refresh perioperative personnel’s
knowledge of hand hygiene and instill a new sense
of urgency to protect patients and health care
workers from the potential of developing an
infection and spreading it to others.
References
1. Recommended practices for hand hygiene. In: Perioperative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2013:63-74.
2. WHO Guidelines on Hand Hygiene in Health Care.
Geneva, Switzerland: World Health Organization; 2009.
http://whqlibdoc.who.int/publications/2009/9789241597906_
eng.pdf. Accessed September 9, 2013.
3. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. MMWR Recomm Rep.
2002;51(RR-16):1-45.
4. How to Handwash? [poster]. Geneva, Switzerland: World
How_To_HandWash_Poster.pdf. Accessed September 13,
2013.
5. How to Handrub? [poster]. Geneva, Switzerland: World
www.aornjournal.org
How_To_HandRub_Poster.pdf. Accessed September 13,
2013.
6. Guide to Implementation: A Guide to the Implementation
of the WHO Multimodal Hand Hygiene Improvement
Strategy. Geneva, Switzerland: World Health Organization; 2009. http://whqlibdoc.who.int/hq/2009/WHO_IER_
PSP_2009.02_eng.pdf. Accessed September 9, 2013.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,
CNOR, is the director, Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr
Spruce has no declared affiliation that could be
perceived as posing a potential conflict of interest in the publication of this article.
Check back in January 2014 for the next “Back to Basics” topic: Hygiene and Cleanliness.
AORN Journal j 457
EXAMINATION
1.2
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge of best practices related to hand hygiene
and performing surgical hand antisepsis.
OBJECTIVES
2. Discuss best practices that could enhance safety in the perioperative area.
3. Describe implementation of evidence-based practice in relation to perioperative
nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1.
2.
5.
Hand hygiene practices can
1. decrease microorganism transmission to patients and health care workers.
2. jeopardize safety in the perioperative area if
not performed correctly.
3. significantly improve the burden on the
global health care system if performed as
recommended.
a. 1 and 3
b. 1 and 2
c. 2 and 3
d. 1, 2, and 3
According to the World Health Organization,
agents used for surgical hand preparation should
1. be fast-acting and persistent.
2. contain a nonirritating antimicrobial preparation.
3. be chlorine based to kill spores.
4. have broad-spectrum activity.
458 j AORN Journal
!
No 5
significantly reduce microorganisms on intact
skin.
a. 1 and 2
b. 1 and 3
c. 1, 2, 4, and 5
d. 1, 2, 3, 4, and 5
3.
According to AORN, hand hygiene should be
performed
1. after removing personal protective equipment.
2. before and after every patient contact.
3. on arrival and before leaving the facility.
4. when hands are visibly soiled.
a. 1 and 3
b. 2 and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4
4.
Evidence shows that a failure to wash hands appropriately is the leading cause of the spread of
multidrug-resistant organisms among patients.
a. true
b. false
! AORN, Inc, 2013
CE EXAMINATION
5.
Strategies that can be used to improve compliance
with hand hygiene protocols include
1. creating and implementing a facility action plan.
2. establishing protocols for hand hygiene.
3. mandating one brand of hand hygiene products
for all personnel to use.
www.aornjournal.org
4.
5.
monitoring hand hygiene practices and reporting on findings to personnel.
providing personnel with educational materials.
a. 2 and 4
b. 1, 2, 4, and 5
c. 1, 3, 4, and 5
d. 1, 2, 3, 4, and 5
AORN Journal j 459
LEARNER EVALUATION
1.2
T
his evaluation is used to determine the extent
to which this continuing education program
met your learning needs. Rate the items as
described below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss common areas of concern that relate to
perioperative best practices.
Low 1. 2. 3. 4. 5. High
2. Discuss best practices that could enhance safety in
the perioperative area.
Low 1. 2. 3. 4. 5. High
3. Describe implementation of evidence-based practice
in relation to perioperative nursing care.
Low 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
5. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
7. Will you change your practice as a result of reading
this article? (If yes, answer question #7A. If no,
answer question #7B.)
460 j AORN Journal
!
No 5
www.aorn.org/CE
7A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: _______________________________
7B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: ________________________________
8. Our accrediting body requires that we verify
the time you needed to complete the 1.2 continuing education contact hour (72-minute)
program: _________________________________
! AORN, Inc, 2013

vivo comparative efficacy of three surgical hand preparation agents

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