Pre-Surgical Hand Antisepsis: Current Recommendations

Introduction: This article appeared in Veterinary Surgery, the official journal for the ACVS in 2011.¹ Shortly after it was published we switch from chlorhexidine to an alcohol rub (Sterillium, see Tech Tip this issue). We had used chlorhexidine for at least 15 years and prior to that iodine base surgical scrubs for an additional 15 or more years. We stopped the iodine products because we were afraid of the amount of iodine we inhaled. It would turn the walls of our scrub room orange in a short time! Chlorhexidine was very drying to our skin. This was especially noticeable in the winter months when we would develop painful open cracks thru our dermis of our finger tips. Since we no longer actually scrub our hands with a surgical brush our skin has fewer open dermal penetrating wounds. We realized we were way behind on our surgical hand antisepsis protocol based on the research and the World Health Organization recommendations. Based on this articles survey results most of our ACVS/ECVS colleagues were not aware as well. Since most of our referring veterinary colleagues probably do not read Veterinary Surgery I decide to share this information with you. Thus the reason for selecting this topic for this months newsletter. 

History of Presurgical Hand Antisepsis and Current Research

Before microorganisms were discovered as vectors or causative agents of disease, hand hygiene was known to reduce the risk of disease transmission. Semmelweis noticed a dramatic decrease in mortality rates from childbed fever in the Vienna maternity ward after he had introduced hand scrubbing with chlorinated lime solutions before every physical examination. Nevertheless, it was only after recognition of Lister's work on reduction of surgical site infections (SSIs) by means of disinfection that surgical hand antisepsis became internationally recognized. Soon after, Pasteur stated ''Instead of forcing ourselves to trying to kill microbes in wounds, would it not be more reasonable not to introduce them"; a statement that remains true. Despite this, SSI continues to be one of the most frequent types of nosocomial infection even though presurgical antiseptic treatment of the hands of surgical staff has become a globally accepted procedure.

SSI remains a source of increasing human and veterinary health care costs because of delayed wound healing, increased use of antibiotics, and increased hospital stay, and can result in fatal outcomes. The topic of hand disinfection, however, seems to generate little interest among veterinary surgeons compared with human surgery. A brief literature search (Pubmed accessed November 1, 2011) using the terms ''surgical hand disinfection'' yielded 815 hits in human medicine over the last 50 years, whereas the inclusion of ''veterinary'' yielded only 6 conclusive hits. 

Risk of SSI correlates directly with dose and the virulence of microbial contamination and the patient's resistance. Generally, there is increased risk of SSI when the bacterial count in wounds is >10⁵ bacteria/g tissue. Use of gloves significantly decreases surgical site contamination; however, glove perforation, principally involving the index finger of the nondominant hand occur in 67% of surgical interventions, highlighting the importance of hand preparation. The objective of surgical hand antisepsis is to eliminate or reduce skin flora before gloving to diminish the risk of SSI. Strategies to prevent the transfer of microbial skin flora from the surgeon's hands must consider the various categories of flora: transient, resident, or infectious flora. Resident skin flora is mainly found under the superficial cells of the stratum corneum and are not usually regarded as pathogens on intact skin. Resident flora have a protective function by inducing ''colonization resistance'' by microbial antagonism and competing for nutrients in the ecosystem.

Transient flora acquired by contact with other people, animals, or contaminated environmental surfaces only colonize the superficial layers of intact skin, and are the most common cause for inducing SSI. The hands of surgical staff have higher bacterial counts and more pathogenic organisms than hands of others. One reason for this is the increased contact with infected wounds, but far more important is the effect of the products used on skin integrity and skin resident flora. Each hand wash detrimentally alters the water lipid layer of the superficial skin creating a loss of protective agents such as amino acids and natural antimicrobial factors. Prolonged or repeated washing leads to damaged barrier function of the stratum corneum resulting in the skin becoming more permeable for toxic agents and bacteria. Moreover, scrubbing causes small excoriations and thus damages the skin, also increasing the risk of colonization of the skin by pathogenic species.

Three different types of antiseptic solutions for surgical hand antisepsis are available: aqueous scrubs, alcohol- based rubs, and alcohol rubs each containing additional active ingredients. Aqueous solutions contain either povidone iodine or chlorhexidine-gluconate  have been the standard procedure for many decades although alcohol-based hand rubs (AHR) have been described for this purpose for more than a century. The popularity of AHRs is increasing among human surgeons because AHR have rapid and immediate action, are considerably faster to use than disinfecting soap scrubs, and cause less skin damage after repeated use. The World Health Organization (WHO) currently recommends this method of hand asepsis.

Reference: 

¹ Verwilghen, D. et al; Presurgical Hand Antisepsis: Concepts and Current Habits of Veterinary Surgeons. Veterinary Surgery, Volume 40, Issue 5, pages 515-521, July 2011.