WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
healthy volunteers outside the operating theatre are the best
evidence currently available. In the USA, antiseptic preparations
intended for use as surgical hand preparation (based on the
FDA TFM of 17 June 1994) 198 are evaluated for their ability
to reduce the number of bacteria released from hands: a)
immediately after scrubbing; b) after wearing surgical gloves for
6 hours (persistent activity); and c) after multiple applications
over 5 days (cumulative activity). Immediate and persistent
activities are considered the most important. <strong>Guidelines</strong> in
the USA 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
(see Part I, Section 10). 532 In Europe, all products must be at
least as efficacious as a reference surgical rub with n-propanol,
as outlined in the European Norm EN 12791. In contrast to
the USA’ guidelines, only the immediate effect after the hand
hygiene procedure and the level of regrowth after 3 hours under
gloved hands are measured. The cumulative effect over 5 days
is not a requirement of EN 12791.
Most guidelines prohibit any jewellery or watches on the hands
of the surgical team (Table I.13.1). 58,529,533 Artificial fingernails are
an important risk factor, as they are associated with changes
of the normal flora and impede proper hand hygiene. 154,529
Therefore, they should be prohibited for the surgical team or in
the operating theatre. 154,529,534
13.4 Surgical hand antisepsis using medicated soap
The different active compounds included in commercially
available handrub formulations are described in Part I, Section
11. The most commonly used products for surgical hand
antisepsis are chlorhexidine or povidone-iodine-containing
soaps. The most active agents (in order of decreasing activity)
are chlorhexidine gluconate, iodophors, triclosan, and plain
soap. 282,356,378,529,535-537 Triclosan-containing products have also
been tested for surgical hand antisepsis, but triclosan is mainly
bacteriostatic, inactive against P. aeruginosa, and has been
associated with water pollution in lakes. 538,539 Hexachlorophene
has been banned worldwide because of its high rate of dermal
absorption and subsequent toxic effects. 70,366 Application
of chlorhexidine or povidone-iodine result in similar initial
reductions of bacterial counts (70–80%), reductions that
achieves 99% after repeated application. Rapid regrowth
occurs after application of povidone-iodine, but not after use
of chlorhexidine. 540 Hexachlorophene and triclosan detergents
show a lower immediate reduction, but a good residual effect.
These agents are no longer commonly used in operating rooms
because other products such as chlorhexidine or povidoneiodine
provide similar efficacy at lower levels of toxicity, faster
mode of action, or broader spectrum of activity. Despite
both in vitro and in vivo studies demonstrating that it is less
efficacious than chlorhexidine, povidone-iodine remains one of
the widely-used products for surgical hand antisepsis, induces
more allergic reactions, and does not show similar residual
effects. 271,463 At the end of a surgical intervention, iodophortreated
hands can have even more microorganisms than before
surgical scrubbing. Warm water makes antiseptics and soap
work more effectively, while very hot water removes more of the
protective fatty acids from the skin. Therefore, washing with hot
water should be avoided. The application technique is probably
less prone to errors compared with handrubbing (Table I.13.2)
as all parts of the hands and forearms get wet under the tap/
faucet. In contrast, all parts of the hands and forearms must
actively be put in contact with the alcohol-based compound
during handrubbing (see below).
13.4.1 Required time for the procedure
Hingst and colleagues compared hand bacterial counts
after 3-minute and 5-minute scrubs with seven different
formulations. 378 Results showed that the 3-minute scrub
could be as effective as the 5-minute scrub, depending on
the formula of the scrub agent. Immediate and postoperative
hand bacterial counts after 5-minute and 10-minute scrubs
with 4% chlorhexidine gluconate were compared by O’Farrell
and colleagues before total hip arthroplasty procedures. 512
The 10-minute scrub reduced the immediate colony count
more than the 5-minute scrub. The postoperative mean log
CFU count was slightly higher for the 5-minute scrub than for
the 10-minute scrub; however, the difference between postscrub
and postoperative mean CFU counts was higher for
the 10-minute scrub than the 5-minute scrub in longer (>90
minutes) procedures. The study recommended a 5-minute
scrub before total hip arthroplasty.
A study by O’Shaughnessy and colleagues used 4%
chlorhexidine gluconate in scrubs of 2, 4, and 6-minutes
duration. A reduction in post-scrub bacterial counts was found
in all three groups. Scrubbing for longer than 2 minutes did not
confer any advantage. This study recommended a 4-minute
scrub for the surgical team’s first procedure and a 2-minute
scrub for subsequent procedures. 541 Bacterial counts on hands
after 2-minute and 3-minute scrubs with 4% chlorhexidine
gluconate were compared. 542 A statistically significant difference
in mean CFU counts was found between groups with the higher
mean log reduction in the 2-minute group. The investigators
recommended a 2-minute procedure. Poon and colleagues
applied different scrub techniques with a 10% povidone-iodine
formulation. 543 Investigators found that a 30-second handwash
can be as effective as a 20-minute contact with an antiseptic
in reducing bacterial flora and that vigorous friction scrub is not
necessarily advantageous.
13.4.2 Use of brushes
Almost all studies discourage the use of brushes. Early in
the 1980s, Mitchell and colleagues suggested a brushless
surgical hand scrub. 544 Scrubbing with a disposable sponge
or combination sponge-brush has been shown to reduce
bacterial counts on the hands as effectively as scrubbing with a
brush. 511,545,546 Recently, even a randomized, controlled clinical
trial failed to demonstrate an additional antimicrobial effect by
using a brush. 547 It is conceivable that a brush may be beneficial
on visibly dirty hands before entering the operating room.
Members of the surgical team who have contaminated their
hands before entering the hospital may wish to use a sponge
or brush to render their hands visibly clean before entering the
operating room area.
55