Comparison of two alcohol-based surgical scrub solutions with an iodine-based scrub brush for presurgical antiseptic effectiveness in a community hospital. An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts. The effect of surgical handwashing routines on the microbial counts of operating room nurses. Usefulness of an alcohol solution of N-duopropenide for the surgical antisepsis of the hands compared with handwashing with iodine-povidone and chlorhexidine: clinical essay. Are sterile water and brushes necessary for hand washing before surgery in Japan? Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels. Comparison of a one-step iodophor skin preparation versus traditional preparation in total joint surgery. Paint-only is equivalent to scrub-and-paint in preoperative preparation of abdominal surgery sites.
The antiseptic effectiveness and acceptability of a commercial alcohol-based waterless (ABWL) and an alcohol-based water-aided (ABWA) scrub solution were compared with a brush-based iodine solution (BBIS) under conditions encountered in community hospital operating rooms. This randomized partially blinded study was based on guidelines from the American Society for Testing and Methods. The three scrub solutions were compared for antimicrobial efficacy, using criteria within the Food and Drug Administration's Tentative Final Monograph for Healthcare Antiseptic Products (FDA-TFM), and for participants' acceptance of the products. Volunteer surgical staff that worked daily in the same operating room for the entire duration of the study were enrolled. In total, 1126 surgical scrub procedures were performed over the duration of the study. Only the ABWL met all of the FDA-TFM criteria. The BBIS performed better than both of the alcohol-based solutions at the end of Day 1 (P=0.03), but the ABWL was more efficacious than the ABWA and the BBIS at the end of Days 2 and 5 (P=0.02 and 0.01, respectively). When colony-count reductions were compared over the entire duration of the study, there was no significant difference between the three solutions (P=0.2). The participants found the ABWL easiest to use (P<0.001), with the fewest adverse effects on skin (P=0.007), and it was their preferred product (P<0.001). Although both of the commercially available alcohol-based solutions may be considered as acceptable alternatives to the BBIS for presurgical antisepsis, the ABWL was found to have significantly higher user acceptability. Five protocols for surgical handwashing (scrubbing) were evaluated for their efficiency of removal of micro-organisms and their drying effect on the skin. The scrubbing protocols tested were: (1) an initial scrub of 5 min and consecutive scrubs of 3.5 min with chlorhexidine gluconate 4% (CHG-5); (2) an initial scrub of 3 min and consecutive scrubs of 2.5 min with chlorhexidine gluconate 4% (CHG-3); (3) an initial scrub of 3 min and consecutive scrubs of 2.5 min with povidone iodine 5% and triclosan 1% (PI-3); (4) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (IPA); and (5) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (EA). A convenience sample of 23 operating theatre nurses completed each scrub protocol for one week in a randomized order. A week of normal work activities intervened between each protocol. Subjects were assessed before commencing and after completing the week of each protocol to determine changes in the microbial counts and skin condition of the hands. Specimens for microbial analysis were collected before, immediately after and 2 h after an initial scrub, and 2 h after a consecutive scrub. The CHG-5, CHG-3 and PI-3 protocols, which used detergent-based antiseptics only, were compared with protocols incorporating an alcohol-based antiseptic (IPA and EA). The protocols incorporating alcohol-based antiseptics and the CHG-5 protocol were generally associated with the lowest post-scrub numbers of colony forming units (cfu). No difference between the CHG-5 protocol and the alcohol-based antiseptics was found at the beginning of the test week, but after exclusive use of the respective protocols for a week, the alcohol-based antiseptics were associated with significantly lower cfu numbers in two out of the three post-scrub samples (P = 0.003, P = 0.035). Although virtually no statistically significant differences in skin condition were found, many subjects reported the alcohol-based antiseptic protocols to be less drying on the skin. The findings of this study support the proposition that a scrub protocol using alcohol-based antiseptics is as effective and no more damaging to skin than more time-consuming, conventional methods using detergent-based antiseptics. Many factors may affect the efficiency of handwashing techniques. This study examined two interdependent factors: the time taken to wash the hands and the type of antiseptic solution used. A 3-minute initial scrub and 30-second consecutive scrub regimen was compared with a current standard regimen of a 5-minute initial scrub and a 3-minute consecutive scrub. Chlorhexidine gluconate 4% and povidone-iodine 7.5% were the antiseptics used in the two regimens. The sample (n = 34) was drawn from nurses employed in the operating room suite of a 950-bed hospital. Chlorhexidine gluconate was found to be responsible for lower numbers of colony-forming units of bacteria than povidone-iodine. The duration of the scrub had no significant effect on the numbers of bacteria when povidone-iodine was used. The optimal regimen was found to be the 5-minute initial and 3-minute consecutive scrubs with chlorhexidine gluconate. The usual surgical antisepsis involves scrubbing the skin with antiseptic solutions. This procedure can damage the skin, with the subsequent risk of infection for the patient. There are several efficient and quick-acting antiseptic alcohol solutions that require no scrubbing.
                We compare four alcohol solutions with the classic surgical handwashing products (chlorhexidine and iodine-povidone), in both in vitro (pigskin germ carriers) and in vivo studies. The latter (clinical essays) were done with healthy volunteers (crossed design) as well as with 154 surgical team members (Plastic Surgery or Traumatology), whose hand microbial flora were measured before and after scrubbing up and after surgery.
                Because of its efficiency in the germ carrier, we chose a solution of N-duopropenide in 60 degrees alcohol with emollients for further comparison with the standard surgical scrub: 4% chlorhexidine and 7.5% iodine-povidone. The quantitative, semiquantitative, and qualitative results obtained with N-duopropenide without scrubbing were better in the healthy volunteers and surgical teams. This product reduced hand microorganisms by more than 2 log, and maintained the reduction for the entire study period. Four percent chlorhexidine initially reduced colonization more than 2 log but lost part of its effect over time during the surgical intervention. Last, 7.5% iodine-povidone reduced the germs by 1 log but at the end of surgery there were even more germs than before washing.
                Because of its efficacy, persistent effect, and skin protection, we advise that scrubbing with classic antiseptic solutions be replaced with gentle washing with an alcohol solution such as N-duopropenide in alcohol.
                Copyright 2000 Academic Press. To examine whether sterile water and brushes are necessary for hand washing before surgery.
                Twenty-two operating room nurses were randomly divided into two groups as follows: 11 nurses who used 7.5% povidone iodine (PVI group) and another 11 nurses who used 4% chlorhexidine gluconate (CHG group) to wash their hands using the rubbing method. All the nurses were examined for bacterial contamination of their hands before and after surgical hand rubbing. We used tap water to wash the hands at the sink used for washing surgical instruments in the operating room and non sterilized plastic brushes.
                No bacteria were detected in the tap water. Before washing the hands, the number of bacteria detected was 5.0 x 10(3) cfu/H in the PVI group and 4.0 x 10(3) cfu/H in the CHG group, which were similar in both groups. After washing the hands, the median value of the bacteria decreased to 8.7 x 10(2) cfu/H in the PVI group and 0 cfu/H in the CHG group.
                Sterile water and brushes are not necessary for preoperative scrubbing up. When using tap water for surgical hand washing, 1) the hand-rubbing method should be used; 2) a quick-alcohol-based disinfectant scrub should be used; 3) the concentration of free chloride in the water should be maintained at over 0.1 PPM; 4) the bacterial contamination of the water should be checked; and 5) the faucet should be routinely cleaned and sterilized. This report describes three different investigations undertaken to demonstrate the advantage of fluid alcoholic hand disinfectants. In the first study, the skin compatibility of Sterillium, a liquid alcoholic rub-in hand disinfectant was compared with that of Hibiscrub, a water-based handwashing antiseptic. Using various parameters such as image analysis of removed squames (D-squames), skin roughness or transepidermal water loss, Hibiscrub was found to be significantly inferior to Sterillium. Hibiscrub caused skin irritation in 15 volunteers who could not complete the test. In a second study, the microbicidal efficacy of Sterillium and Hibiscrub was tested in surgical hand disinfection. The microbial reduction by Sterillium was significantly greater than that of Hibiscrub, immediately after application as well as after the surgical procedure. In a third study, certain alcoholic gels were tested according to the EN 1500 'hygienic hand disinfection'. None of the gels tested passed the EN 1500 within 30s. However, Sterillium met the EN 1500 requirement within 30s. We conclude that Sterillium is superior to Hibiscrub in terms of skin tolerance and microbicidal efficacy in surgical hand disinfection. It is also superior to alcoholic gels. The purpose of this study was to compare a traditional two-step method of preoperative skin preparation using aqueous iodophors with a one-step method using an iodophor-in-alcohol solution. Sixty patients having clean total joint surgery were randomly divided into two preoperative skin preparation groups (30 in each). In one group, the skin was prepared with a traditional five-minute aqueous iodophor scrub followed by the application of an aqueous iodophor solution as a paint. In the other group, the skin was prepared with a one-step application of a water-insoluble iodophor-in-alcohol solution applied as a paint. Bacterial colony counts were made by sampling the incision area with culture plates before skin preparation and just prior to wound closure. The one-step application of a water-insoluble iodophor-in-alcohol solution was equally as effective as the traditional scrub-and-paint preparation in reducing the number of bacteria about the operative site. The water-insoluble preparation also resulted in significantly improved drape adhesion as compared to the standard scrub-and-paint procedure. The one-step water-insoluble iodophor-in-alcohol solution fulfills the requirements for an operative site skin preparation and significantly improves drape adhesion. It is more convenient, easier to apply, less time consuming, and potentially less expensive than the traditional scrub-and-paint method. Antiseptic preoperative skin site preparation is used to prepare the operative site before making a surgical incision. The goal of this preparation is a reduction in postoperative wound infection. The most straightforward technique necessary to achieve this goal remains controversial.
                A prospective randomized trial was designed to prove equivalency for two commonly used techniques of surgical skin site preparation. Two hundred thirty-four patients undergoing nonlaparoscopic abdominal operations were consented for the trial. Exclusion criteria included presence of active infection at the time of operation, neutropenia, history of skin reaction to iodine, or anticipated insertion of prosthetic material at the time of operation. Patients were randomized to receive either a vigorous 5-minute scrub with povidone-iodine soap, followed by absorption with a sterile towel, and a paint with aqueous povidone-iodine or surgical site preparation with a povidone-iodine paint only. The primary end point of the study was wound infection rate at 30 days, defined as presence of clinical signs of infection requiring therapeutic intervention.
                Patients randomized to the scrub-and-paint arm (n = 115) and the paint-only arm (n = 119) matched at baseline with respect to age, comorbidity, wound classification, mean operative time, placement of drains, prophylactic antibiotic use, and surgical procedure (all p > 0.09). Wound infection occurred in 12 (10%) scrub-and-paint patients, and 12 (10%) paint-only patients. Based on our predefined equivalency parameters, we conclude equivalence of infection rates between the two preparations.
                Preoperative preparation of the abdomen with a scrub with povidone-iodine soap followed by a paint with aqueous povidone-iodine can be abandoned in favor of a paint with aqueous povidone-iodine alone. This change will result in reductions in operative times and costs.
Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering.
Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands.
There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.