Surgical hand antisepsis to reduce surgical site infection.

BACKGROUND: Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients.

OBJECTIVES: To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005).

SELECTION CRITERIA: Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS: Three authors independently assessed studies for selection, trial quality and extracted data.

MAIN RESULTS: Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.

AUTHORS' CONCLUSIONS: 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.