Surgical hand preparation: state-of-the-art

Improving Quality and Compliance of Surgical Hand Scrubbing Practices: A Clinical Audit

Background Surgical site infections (SSIs) are a critical concern in healthcare, particularly in developing countries, where they are among the most prevalent and challenging hospital-acquired infections. Adherence to proper hand hygiene practices is essential to prevent SSIs. However, compliance among surgical teams remains suboptimal due to factors such as time constraints, lack of training, and resource limitations. This study evaluates and enhances adherence to surgical hand scrubbing protocols at Osman Degna Teaching Hospital using World Health Organization (WHO) guidelines. Methods An observational cross-sectional audit was conducted in two cycles between August and October 2024, with 54 observations per cycle. Baseline adherence was assessed in the first cycle. Targeted interventions, including video demonstrations, hands-on training, and feedback, were implemented before the second cycle. Data were collected using a structured checklist and analyzed quantitatively to compare compliance rates and qualitatively to identify barriers to adherence. Results Compliance with hand scrubbing protocols improved significantly from 63.1% in the first cycle to 94.3% in the second. The most notable improvement (51.5%) was observed in rotational rubbing with clasped fingers. Other areas, including scrubbing palms and rinsing hands, showed substantial increases (30.3-42%). These findings highlight the effectiveness of structured training and feedback in enhancing adherence. Conclusion Targeted educational interventions significantly improved compliance with surgical hand scrubbing protocols, contributing to better infection control practices. While these improvements demonstrate the potential of training programs, continued efforts and long-term strategies are necessary to sustain progress and further reduce the risk of SSIs.

Implementing an Internal Audit: Evaluating Hand Scrub Compliance in a Tertiary Care Hospital

Background Aseptic protocol adherence and sterilization are the most important factors in a patient's satisfactory recovery after surgery. The standard hand scrubbing procedure helps control infection and keeps the surgical site clean by adhering to aseptic principles. Methods Thirty-six young residents and house officers participated in this prospective audit after ethical clearance was obtained. The World Health Organization (WHO) standard criteria were adhered to both before and after the intervention. Participants were observed in the surgical operation theatre (OT) without prior notice to ensure hand hygiene compliance before surgical procedures. The intervention included a video presentation as well as a live demonstration. Results Only 64.41% (n=23) of residents and house officers followed the recommended standard hand hygiene procedures before the intervention. This percentage rose to 93.92% (n=33) following the intervention, suggesting a noteworthy improvement. Conclusion Significant changes in the acceptance rates for the essential requirements of hand hygiene were observed after the evaluation in the second cycle. Adhering to WHO guidelines for procedures will help reduce the risk of infections and promote awareness of asepsis in practice.

Microbiological Analysis of Surgeons' Hands in a Public Hospital in São Luis, Maranhão State, Brazil: A Cross-Sectional Study

Antisepsis of the hands of medical personnel is one of the most important steps in the process of patient care, since direct contact can cause the cross-transfer of potentially pathogenic microorganisms at surgical sites. This study aimed to analyze the prevalence of microorganisms on the hands of 131 surgeons in a university hospital before the surgical procedure. Swabs were collected from each clinician's hands before and after handwashing. The samples were placed in a transport medium and immediately delivered to a private clinical analysis laboratory from São Luis-Maranhão. The microorganisms were identified by ionization source mass spectrometry and matrix-assisted laser desorption (MALDI-TOF), and antibiotic susceptibility tests (AST) were performed using the Vitek2 and Phoenix-BD automated system. The results showed a high frequency (100%) of microorganisms before handwashing, but after surgical antisepsis, the rate dropped significantly (p < 0.05) to 27.5%. The gram-positive species most detected were Staphylococcus spp. and Micrococcus luteus, representing 83.9%, followed by gram-negative species, Stenotrophomonas maltophilia, Acinetobacter baumanii, Pseudomonas aeruginosa, Pseudomonas gessardi, Pantoea septica, Serratia marcescens, and Burkholderia lata. The effectiveness of hand antisepsis was 72.5%, demonstrating that surgeons' hands are an important source of microorganisms that can cause infections in hospitalized patients in different care settings.

Investigating Particulate Production in The Operating Suite Following the Use of Waterless Alcohol Based Dry Scrub Versus Traditional Hand Washing and Drying with Commonly Used Surgical Towels: An Experimental Study

BACKGROUND

An often-overlooked item that could cause contamination in the operating suite are the towels used for hand drying following surgical scrub. The purpose of this current study was to determine if there was a difference in the particulate count from different hand drying methods following surgical hand preparation.

METHODS

Three simulated hand drying groups were established: disposable sterilized surgical towels, reusable sterilized surgical towels, and a waterless alcohol-based dry rub. Particle size measurements of 0.3 µm, 5.0 µm, and 10.0 µm were collected at time zero and repeated every minute for 5 minutes for a total of 10 trials each.

RESULTS

Both the reusable and disposable towels produced significantly more particle matter in all size groups compared to the alcohol scrub control group. A comparison analysis and ANOVA testing demonstrated that alcohol dry scrub produced significantly fewer particles compared to both the disposable blue towels (P<0.01) and the reusable green towels (P<0.01). Disposable towels produced significantly more particles in the 0.3 µm count compared to reusable towels (P<0.05).

CONCLUSIONS

An alcohol-based dry rub without using a towel yielded the lowest amount of particulate formation in this experimental model, while reusable surgical towels produced the highest number of particles.

LEVEL OF EVIDENCE

Level II Experimental Study.

Primary versus delayed primary skin closure in operated patients due to perforated peptic ulcer disease: a randomized controlled clinical trial

PURPOSE

Perforated peptic ulcer (PPU) is a life-threatening complication of peptic ulcer disease. This condition is characterized by a dirty abdomen that predisposes to postoperative wound infection. Delayed primary skin closure is occasionally preferred over primary closure to reduce the risk of surgical site infection in dirty abdominal wounds. In primary skin closure, the skin is sutured immediately after surgery. Meanwhile, in delayed primary skin closure, the incision is left open, and sutured after 2-5 days. The current research aimed to compare the risk for surgical site infection, length of hospitalization, and mortality rate between primary versus delayed primary skin closure among patients who underwent surgery for PPU.

METHODS

This single-blind randomized clinical trial included 120 patients who were randomly allocated into the primary and delayed primary closure groups. A research assistant who was blinded to the study examined the wounds for surgical site infection based on the 1992 Center for Disease Control criteria. The outcomes were mortality rate and duration of hospitalization.

RESULTS

The delayed primary and primary closure groups did not significantly differ in terms of postsurgical wound infection occurring on the 3rd, 7th, 14th, and 30th days after surgery, mortality rate, and duration of hospitalization.

CONCLUSION

In patients who underwent surgery for PPU, delayed primary closure is not recommended over primary closure due to the risk of postoperative surgical site infection.

Use of Vancomycin Mixed Bone Graft and Vancomycin Mixed Saline Wash Before Wound Closure Reduces the Rate of Infection in Lumbar Spine Fusion Surgery

This study aims to evaluate whether surgical site vancomycin mixed in bone grafts and local vancomycin mixed in normal saline wash before wound closure decrease the infection rates in patients undergoing lumbar spinal instrumentation and posterolateral fusion. A retrospective study was performed on cases between 2017 and 2019, who underwent lumbar spine instrumentation and posterolateral fusion for lumbar canal stenosis or listhesis. The routine prophylactic procedures were performed in all patients as per institutional protocol. Patients' records were analysed and categorised into two groups, the vancomycin group (VG), where vancomycin mixed in bone graft and normal saline wash was used at the surgical site, and the control group (CG), where vancomycin was not used. The study included 63 patients, 31 in VG and 32 in CG. There is no statistical difference in age, sex, and diabetes mellitus in both groups. A total of seven cases were infected, six in CG (6/32) and one in VG (1/31). Out of six infections in CG, three patients had diabetes and four infected cases underwent surgery for debridement. In VG, the only single case got infected and treated with intravenous antibiotics. We found that the use of vancomycin added to the bone graft and normal saline in posterior lumbar spinal instrumentation and posterolateral fusion is associated with significantly lower rates of infection (p value=0.049).

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

Using Waterless Alcohol-based Antiseptic for Skin Preparation and Active Thermal Support in Laboratory Rats

Rodents are frequently used for models that require surgical procedures. At our institution, laboratory rats are increasingly preferred for investigations of neurologic disorders, cardiovascular interventions, and assessment and treatment of addictive and depressive behaviors. For these types of studies, surgical preparations of the head and neck areas are necessary for catheterization and instrumentation. Based upon our former work in laboratory mice, we sought to improve rat surgery outcomes and confirm the efficacy of a waterless alcohol-based (WAB) antiseptic for skin disinfection prior to incision. In addition, we wanted to investigate whether active warming efforts improved perioperative body temperatures for rats to aid in return to consciousness. Prior to cranial surgical incision and placement in stereotactic equipment, rats were assessed after skin preparation with WAB and after thermal interventions, including prewarming cages for 30 min before anesthesia and delivery of warmed fluid (NaCl) supplementation. Core temperatures were recorded and aerobic culture swabs collected from surgical sites at multiple time points. As previously shown in mice, bacterial counts in rats were effectively diminished by WAB agents. Assessment of intraoperative body temperature trajectories did not identify appreciable differences between control rats and rats that were exposed to prewarming or warmed fluid supplementation or both. However, heavier male rats recovered more rapidly from isoflurane anesthesia than did lighter male and female rats. Although these thermal support measures did not significantly improve anesthetic recovery times in rats, animals warmed for 30 min trended toward a faster return to righting reflex after exposure to isoflurane. These findings confirm that WAB antiseptic is an acceptable option for skin preparation in rats and suggest that continued evaluation of thermal interventions remains of interest for improved outcomes in rat surgery.

Design, Fabrication, and Testing of a Novel Surgical Handwashing Machine

Background. Surgical hand scrub is strongly recommended as an essential measure to reduce surgical site infections (SSIs). SSI results in morbidity and additional cost. Micropunctures may occur on surgical gloves during operation, thus hand scrub cannot be omitted in any condition. Generally speaking, the adequacy of hand scrub is decided by the surgeon. Only occasionally, surveillance of hygienic status of hands is performed after scrub. Therefore, the potential exists that suboptimal handwash leads to SSIs. There are standards for preoperative handwash, but all of them are operator dependent, and continuous surveillance is actually impossible. One solution is to omit the role of surgeon in handwashing. This can be achieved by designing a standard procedure, performed mechanically by a machine, considering the detailed requirements of hygienic surgical hand scrub. The goal of this study was to develop a procedure that works on the design, fabrication, and trial of a new handwashing machine, for surgical hand scrub. Methods. A machine with a reciprocal spraying mechanism was designed that covers from the fingertips up to the elbow. Various combinations of staged irrigations with antiseptic solutions and water were to be programmed and implemented. Clinical experiments were performed several times with different handwashing programs, and swabs were taken from the skin surface and creases. Results. There was no microbial growth after 72 hours with any handwashing program. Conclusion. The preliminary experiments with this new handwashing machine show promising results for its application in surgical hand scrub.

Are three antiseptic paints needed for safe preparation of the surgical field? A prospective cohort study with 239 patients

Background

Preoperative skin antisepsis is an essential component of safe surgery. However, it is unclear how many antiseptic paints are needed to eliminate bacteria prior to incision. This study compared microbial skin counts after two and three antiseptic paints.

Methods

We conducted a prospective cohort study in non-emergency patients receiving a cardiac/abdominal surgery with standardized, preoperative skin antisepsis consisting of an alcoholic compound and either povidone iodine (PI) or chlorhexidine (CHX). We obtained three skin swabs from the participant’s thorax/abdomen using a sterile template with a 25 cm² window: After collection of the first swab prior to skin antisepsis, and once the second and third application of PI/CHX had dried out, we obtained a second and third swab, respectively. Our primary outcome was the reduction in microbial skin counts after two and three paints of PI/CHX.

Results

Among the 239 enrolled patients, there was no significant difference in the reduction of mean square root-transformed microbial skin counts with three versus two paints (P = 0.2). But distributions of colony forming units (CFUs) decreased from paint 2 to 3 in a predefined analysis (P = 0.002). There was strong evidence of an increased proportion of patients with zero CFU after paint 3 versus paint 2 (P = 0.003). We did not identify risk factors for insufficient reduction of microbial skin counts after two paints, defined as the detection of > 5 CFUs and/or ≥ 1 pathogens.

Conclusions

In non-emergency surgical patients, three antiseptic paints may be superior to two paints in reducing microbial skin colonization prior to surgery.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves, and gowns: proposal for a risk-adapted approach to ensure patient and healthcare worker safety

The coronavirus disease 2019 (COVID-19) pandemic has caused a huge demand for alcohol-based hand rubs, medical gloves, face masks, and gowns in healthcare and from the public. More and more hospitals face a serious shortage of these articles. We propose a risk-adapted approach to ensure adequate patient and healthcare worker safety for as long as possible.

Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries

Background: The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient. Methods: Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs. Results: Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs. Conclusion: The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.

Intrawound Treatment for Prevention of Surgical Site Infections in Instrumented Spinal Surgery: A Systematic Comparative Effectiveness Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To determine the efficacy of intrawound treatments in reducing deep surgical site infections (SSIs) in instrumented spinal surgery.

METHODS

The electronic databases MEDLINE, EMBASE, and Cochrane were systematically searched for intrawound treatments for the prevention of SSIs in clean instrumented spine surgery. Both randomized controlled trials and comparative cohort studies were included. The results of included studies were pooled for meta-analysis.

RESULTS

After full text- and reference screening, 20 articles were included. There were 2 randomized controlled trials and 18 observational studies. Sixteen studies investigated the use of intrawound antibiotics, and 4 studies investigated the use of intrawound antiseptics. The relative risk of deep SSI for any treatment was 0.26 (95% confidence interval [CI] 0.16-0.44, P < .0001), a significant reduction compared with controls receiving no treatment. For patients treated with local antibiotics the relative risk was 0.29 (95% CI 0.17-0.51, P < .0001), and patients treated with local antiseptics had a relative risk of 0.14 (95% CI 0.05-0.44, P = .0006).

CONCLUSIONS

Both the use of antibiotic and antiseptic intrawound prophylactics was associated with a significant 3 to 7 times reduction of deep SSIs in instrumented spine surgery. No adverse events were reported in the included studies.

Adaptive bacterial response to low level chlorhexidine exposure and its implications for hand hygiene

Chlorhexidine digluconate (CHG) is commonly used in healthcare, e.g. in skin antiseptics, antimicrobial soaps, alcohol-based hand rubs and oral or wound antiseptics. Aim of the literature review was to evaluate the potential of bacteria to adapt to low level CHG exposure. A maximum 4fold MIC increase to CHG was found after low level exposure in most of the 71 evaluated bacterial species. A strong adaptive mostly stable MIC change was described in strains or isolates of the healthcare-associated species E. coli, S. marcescens and P. aeruginosa (up to 500fold, 128fold or 32fold, respectively). The highest MIC values after adaptation were 2,048 mg/l (S. marcescens) and 1,024 mg/l (P. aeruginosa). A new resistance to tetracycline, gentamicin, meropeneme or triclosan was found in some adapted isolates. In E. coli horizontal gene transfer was induced (sulfonamide resistance by conjugation), pointing out an additional risk of sublethal CHG. The use of CHG in patient care - but also all other settings such as consumer products and households - should therefore be critically assessed and restricted to indications with a proven health benefit or justifiable public health benefits. Additional CHG has no health benefit when used in alcohol-based hand rubs and is not recommended by the WHO. For routine hand washing of soiled hands the use of plain soap is sufficient, CHG in soaps has no health benefit. In surgical hand antisepsis alcohol-based hand rubs should be preferred to CHG soaps. Implementation of these principles will help to reduce avoidable selection pressure.

Comparison of Aqueous and Alcohol-based Agents for Presurgical Skin Preparation Methods in Mice

Preparing the skin of rodents for surgery often involves multiple applications of antiseptic agents. However, fewer applications may achieve the same antiseptic outcome. We evaluated the antimicrobial efficacy and effects on intraoperative body temperature of various surgical scrub agents, including novel waterless alcohol-based (WAB) options. Prior to ventral laparotomy, female C57BL/6 mice were treated with 0.9% saline (control); 70% ethanol; 10% povidone-iodine alternated with saline or 70% ethanol; 2% chlorhexidine digluconate alternated with saline or 70% ethanol; or 1 of 3 WAB products-commercial surgical scrub A, commercial surgical scrub B, or a common commercial hand sanitizer. Core temperatures were recorded, and aerobic culture swabs were collected from the surgical site at multiple time points. Intraoperative temperature trajectories for animals treated with scrub B, 10% povidone-iodine with saline, or hand sanitizer did not differ from saline (control). Temperature trajectories of mice treated with other scrub agents did differ significantly from saline. Bacteria were not detected at the operative site after 3 scrubs of 70% ethanol or 10% povidone-iodine alternated with ethanol, 2 scrubs of scrub A or B, 1 scrub of hand sanitizer, and both 1 and 3 scrubs of 2% chlorhexidine alternated with ethanol. Scrub B and 2% chlorhexidine-ethanol demonstrated prolonged antibacterial efficacy. Histology of corresponding haired skin sections revealed no differences in postoperative healing between groups, and no postoperative infections occurred. These results indicate that various novel WAB disinfectants, particularly scrub B (61% ethanol and 1% chlorhexidine gluconate), mitigate intraoperative temperature effects associated with several traditional agents and combinations. Furthermore, reduction of skin bacterial load without adverse effects on healing was seen with fewer than triplicate applications of most tested agents. Ultimately effective skin preparation can be achieved by using only 1 or 2 applications of scrub, thus rendering the triplicate skin-prep method unnecessary in laboratory mice.

Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers

BACKGROUND

The Socio-Technical Probabilistic Risk Assessment, a proactive risk assessment tool imported from high-risk industries, was used to identify risks for surgical site infections (SSIs) associated with the ambulatory surgery center setting and to guide improvement efforts.

OBJECTIVES

This study had 2 primary objectives: (1) to identify the critical risk factors associated with SSIs resulting from procedures performed at ambulatory surgery centers and (2) to design an intervention to mitigate the probability of SSI for the highest risk factors identified.

METHODS

Inputs included quantitative and qualitative data sources from the evidence-based literature and from health care providers. The Socio-Technical Probabilistic Risk Assessment ranked the failure points (events) on the basis of their contribution to an SSI. The event, entitled "Failure to protect the patient effectively," which included several failure points, was the most critical unique event with the highest contribution to SSI risk.

RESULTS

A total of 51.87% of SSIs in this setting were caused by this failure. Consequently, we proposed an intervention aimed at all 5 major components of this failure.

CONCLUSIONS

The intervention targets improvements in skin preparation; proper administration of antibiotics; staff training in infection control principles, including practices for the prevention of glove punctures; and procedures to ensure the removal of watches, jewelry, and artificial nails.

Comparison of an alcohol-based hand sanitation product with a traditional chlorhexidine hand scrub technique for hand hygiene preparation in an equine hospital

AIMS

To investigate the efficacy of an alcohol gel-based hand antisepsis protocol compared with a traditional chlorhexidine-based protocol under conditions of routine clinical contamination, and following heavy faecal contamination.

METHODS

Twelve adult participants were recruited and on four separate days completed a hand sanitation protocol using a chlorhexidine scrub or an alcohol-based gel, with hands that were grossly clean but contaminated or with faecal contamination. Bacterial samples were obtained from participants' hands before sanitation, immediately after and then 2 hours later. All samples were cultured on blood and MacConkey agar and bacterial colonies counted after 48 hours.

RESULTS

for clean contaminated hands, the percentage reduction in bacterial colonies on blood agar immediately after hand sanitation was similar for both protocols (p=0.3), but was greater for the alcohol gel than chlorhexidine after 2 hours (p=0.005). For hands with faecal contamination, the percentage reduction in bacterial colonies on blood agar was similar for both protocols immediately and 2 hours after sanitation (p>0.2), but positive cultures were obtained on blood agar from samples collected after both protocols, for almost all participants.

CONCLUSIONS

The results indicate equivalent efficacy of the alcohol-based gel and the pre-surgical chlorhexidine protocol.

CLINICAL RELEVANCE

The alcohol-based gel protocol is an effective hand asepsis technique for grossly clean contaminated hands and those following faecal contamination, with comparable efficacy to chlorhexidine based scrub.

Reducing surgical site infections following total hip and knee arthroplasty: an Israeli experience

PURPOSE

To assess the changes observed in surgical site infection (SSI) rates following total joint arthroplasty (TJA) after the introduction of an infection control programme and evaluate the risk factors for the development of these infections.

DESIGN

Prospective cohort study.

SETTING

Large tertiary medical centre in Israel.

METHODS

Data about SSIs and potential prophylaxis-, patient-, and procedure-related risk factors were collected for all patients who underwent elective total hip and total knee arthroplasty during the study period. Multivariant analyses were conducted to determine which significant covariates affected the outcome.

RESULTS

During the 76-month study period, SSIs (superficial and deep) occurred in 64 (4.4%) of 1554 patients. As compared with the 34 (7.7%) SSIs that occurred in the first 25 months, there were 23 (4.7%) SSIs in the following 25 months, and only 7 (1.3%) SSIs in the last third of the study (p = 0.058 and <0.001, respectively). A multiple logistic regression model indicated that risk factors for prosthetic joint infection were a National Nosocomial Infections Surveillance (NNIS) System surgical patient risk index score of 1 (OR 1.8; 95% CI 1.1-3.1) or 2 (OR 2.8; 95% CI 1.2-11.8). The incidence of SSI was not correlated with the timing, nor the duration of antibiotic prophylaxis.

CONCLUSIONS

The introduction of preventive measures and surveillance coincided with a significant reduction in SSIs following TJA in our institution. The risk of infection correlated with higher scores in the NNIS System surgical patient risk.

A COMPARATIVE STUDY BETWEEN POVIDONE-IODINE AND MANUGEL 85 ON SURGICAL SCRUB

Background:

Direct transmission through skin contact is one of ways for disease transmission. Medical staffs have contact with many patients, so their hand can be a factor for the transmission of disease. Surgical scrub is a process that leads to destruction immigrant and stable microbus of hands and arms through friction washing by use of antiseptic solution prior to surgery. The aim of this study was to compare the effectiveness of disinfection of Povidone-Iodine and Manugel 85 in surgical scrub.

Methods:

This study was a clinical trial that done before and after Surgical scrub. 33 person of surgical team in hospital were surveyed during. Four samples were done for every person: first before surgical scrub with Povidone-Iodine solution, second immediately after surgical scrub, then after one week third test done before surgical scrub with Manugel 85, and forth one immediately after surgical scrub. Paired t-test was used for statistical analysis and SPSS analysis.

Results:

Data analysis showed that the effect of Povidone-Iodine and Manugel 85, separately, before and after surgical scrub on number of colonies is significant. But the effect of these two solutions on behalf of number of colonies was not significant. The 100% grown cultures before surgical scrub with Povidone-Iodine solution and 90.91% before surgical scrub with Manugel 85 were staphylococcus.

Conclusion:

The disinfection effect of Povidone-Iodine and Manuge l85 on surgical scrub is the same.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

[Aortofemoral vascular graft infections and their prevention]

Vascular prosthesis infections are potentially severe adverse events following vascular reconstruction. They are often associated with a high morbidity and mortality, especially in the aortofemoral region. The present article outlines the diagnosis, prevention and treatment of vascular graft infections in a clinical setting. The clinical presentation, inflammatory markers, microbiological work-up and imaging studies can contribute to diagnosing a prosthesis infection. Regarding the bacterial spectrum involved in the etiology of prosthesis infections, single organism infections (monoinfections) have become less significant over the past years, whereas infections with multiple organisms now constitute the most abundant microbiological constellation. Also, infections with resistant bacterial strains have been increasing in number over the past years and deserve special consideration. It remains unclear whether both aspects are due to a true epidemiological change or are the result of advanced molecular microbiological diagnostic methods. While during the past decades perioperative antibiotic prophylaxis was regarded as the most important measure for preventing prosthesis infections in vascular surgery, other primary preventive hygiene strategies have been increasingly explored and grouped together in the sense of preventive bundles. In most cases of deep postoperative infections involving a prosthetic device in the aortofemoral region, explantation of the prosthesis will be required. In situ and extra-anatomical reconstructions are often performed in such cases and the decision process to develop an optimal treatment plan must consider several individual factors. In select patients, palliative preservation of the prosthesis despite surrounding infection (i.e. graft salvage) and best conservative management in combination with local surgical measures, such as incision and drainage and vacuum therapy, deserve consideration as a treatment option for patients with a high surgical risk.

Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review

The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure's possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Infection after hand surgery

Postoperative infections are uncommon after hand surgery. Infection can delay recovery and contribute to scarring and stiffness. Measures intended to reduce the risk of infection after hand surgery include hand washing, skin preparation, sterile technique, and prophylactic antibiotics. The role of prophylactic antibiotics for small, clean, elective hand surgery procedures lasting less than 2 hours is debated.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Fighting surgical site infections in small animals: are we getting anywhere?

A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. In this article, current knowledge of SSI risk factors and prevention methods is reviewed. Although new avenues that can be explored in the prevention of SSIs in veterinary medicine are described, the main conclusion drawn is that the best method for prevention of SSI is to adhere to what we already know.

Observational study of patient and surgeon preoperative preparation in ten companion animal clinics in Ontario, Canada

BACKGROUND

Surgical site infections (SSIs) are a recognized risk of any surgical procedure in veterinary medicine. One of the keys to prevention of SSIs is reducing exposure of the surgical site to endogenous and exogenous microbes, beginning in the preoperative period. While guidelines are available for preoperative preparation procedures, there has been no objective investigation of compliance with these recommendations in veterinary practices. The objectives of this pilot study were to describe preoperative patient and surgeon preparation practices in a sample of non-equine companion animal veterinary clinics, and to determine if there were any areas that consistently did not meet current guidelines.

RESULTS

Observation of preparation practices was performed in 10 clinics over 9-14 days each using up to 3 small wireless surveillance cameras. Data were coded for 148 surgical patients, and 31 surgeons performing 190 preoperative preparations. When patient hair removal was observed, it was most commonly done using clippers (117/133, 88%), and in only one case was it performed prior to anesthetic induction. Patient contact time with soap ranged from 10-462 s (average of clinic means 75 s, average of clinic medians 67 s), and with alcohol from 3-220 s (average of clinic means 44 s, average of clinic medians 37 s). Alcohol-based hand rub (AHR) was used preoperatively in 2/10 facilities, but soap-and-water hand scrub was most commonly used at all clinics. Proximal-to-distal scrubbing was noted in 95/142 (67%) of soap-and-water scrubs. Contact time during surgeon hand preparation ranged from 7-529 s (average mean 121 s, average median 122 s) for soap-and-water and from 4-123 s (average mean 25 s, average median 19 s) for AHR. No significant changes in practices were identified over time during the observation period. Practices that did not conform to guidelines available in major companion animal surgical textbooks were commonly observed.

CONCLUSIONS

Some preoperative preparation practices were relatively consistent between clinics in this study, while others were quite variable. Contact times with preoperative preparatory solutions for both patients and surgeons were often shorter than recommended. Evidence-based guidelines for these procedures in veterinary medicine should be established and implemented in order to help reduce preventable SSIs, while maintaining efficiency and cost-effectiveness.

N-chloramines, a promising class of well-tolerated topical anti-infectives

Antibiotic resistance is a growing public health crisis. To address the development of bacterial resistance, the use of antibiotics has to be minimized for nonsystemic applications in humans, as well as in animals and plants. Possible substitutes with low potential for developing resistance are active chlorine compounds that have been in clinical use for over 180 years. These agents are characterized by pronounced differences in their chlorinating and/or oxidizing activity, with hypochlorous acid (HOCl) as the strongest and organic chloramines as the weakest members. Bacterial killing in clinical practice is often associated with unwanted side effects such as chlorine consumption, tissue irritation, and pain, increasing proportionally with the chlorinating/oxidizing potency. Since the chloramines are able to effectively kill pathogens (bacteria, fungi, viruses, protozoa), their application as anti-infectives is advisable, all the more so as they exhibit additional beneficial properties such as destruction of toxins, degradation of biofilms, and anticoagulative and anti-inflammatory activities. Within the ample field of chloramines, the stable N-chloro derivatives of β-aminosulfonic acids are most therapeutically advanced. Being available as sodium salts, they distinguish themselves by good solubility and absence of smell. Important representatives are N-chlorotaurine, a natural compound occurring in the human immune system, and novel mono- and dichloro derivatives of dimethyltaurine, which feature improved stability.

[A systematic review of surgical hand antisepsis utilizing an alcohol preparation compared to traditional products]

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. Twenty-five 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.

Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts

BACKGROUND

Although the surgical scrub is a mandatory and routine procedure, there is no standard recommendation for nail cleaning during the scrub. This study compared the efficacy of nail picks and brushes used for nail cleaning during the surgical scrub in reducing bacterial counts.

METHODS

Sixty circulatory nurses were included in the survey. The nurses were randomized to undertake 1 of 3 surgical hand scrub protocols: using surgical scrub alone (control group), using a nail pick during the surgical scrub, or using a brush during the surgical scrub. Bacterial counts were measured on the dominant hand immediately before the scrub and 1 hour after the scrub using the glove juice method.

RESULTS

The bacterial counts at 1 hour after the surgical scrub were lower in the control group than in the 2 intervention groups, and there was no significant difference between the 2 intervention groups (F = 2.063; P = .136; P > .05).

CONCLUSION

Using nail picks and brushes on nails during the surgical scrub does not provide additional decontamination.

Dermal and pulmonary absorption of propan-1-ol and propan-2-ol from hand rubs

BACKGROUND

It has been shown that nontoxic concentrations of ethanol are absorbed after hand hygiene using ethanol-based hand rubs. This study investigated whether absorption of propan-1-ol and propan-2-ol from commercially available hand rubs results in measurable concentrations after use.

METHODS

The pulmonary and dermal absorption of propanol during hand rubs was investigated. Rubs contained 70% (w/w) propan-1-ol, 63.14% (w/w) propan-2-ol, or 45% (w/w) propan-2-ol in combination with 30% (w/w) propan-1-ol.

RESULTS

Peak median blood levels were 9.15 mg/L for propan-1-ol and 5.3 mg/L for propan-2-ol after hygienic hand rubs and 18.0 mg/L and 10.0 mg/L, respectively, after surgical hand rubs. Under actual surgical conditions, the highest median blood levels were 4.08 mg/L for propan-1-ol and 2.56 mg/L for propan-2-ol. The same procedure performed with prevention of pulmonary exposure through the use of a gas-tight mask resulted in peak median blood levels of 1.16 mg/L of propan-1-ol and 1.74 mg/L of propan-2-ol.

CONCLUSION

Only minimal amounts of propanols are absorbed through the use of hand rubs. Based on our experimental data, the risk of chronic systemic toxic effects caused by hand rubs is likely negligible. However, our study did not evaluate the consequences of long-term daily and frequent use of hygienic hand rubs.

[Prevention of wound infections: basic measures]

Individual patient risk factors for wound infections, such as alcohol abuse, smoking or obesity can usually only be modified to a small extent. Studies have shown a reduction of surgical site infections due to the implementation of a benchmarking surveillance system. In order to prevent surgical site infections a variety of interventions are available, such as glucose control, correction of anemia and malnutrition and antibiotic therapy of infections before elective surgery. Reduction of the microbial skin flora by whole body washing procedures, avoidance of sharp razor shaving, application of antibiotic prophylaxis and correct surgical hand disinfection are additional measures. Intraoperative hypothermia should be avoided and strict compliance with asepsis is mandatory. Postoperative preventive measures include appropriate wound care and rapid removal of wound drainage.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya

Background

The aim of this cluster-randomized, crossover trial was to compare the efficacy of plain soap and water with an alcohol-based handrub for surgical hand preparation and prevention of surgical-site infection (SSI) in a Kenyan rural hospital.

Methods

A total of 3317 patients undergoing clean and clean-contaminated surgery were included. Follow-up data 30 days after discharge were available for 3133 patients (94·5 per cent).

Results

SSI occurred in 255 patients (8·1 per cent), with similar rates for both study arms: 8·3 per cent for alcohol-based handrub versus 8·0 per cent for plain soap and water (odds ratio 1·03, 95 per cent confidence interval 0·80 to 1·33). After adjustment for imbalances between study arms and clustering effects, the main outcome measure remained unchanged (adjusted odds ratio 1·06, 0·81 to 1·38). The duration of surgery and wound contamination class independently predicted SSI. The cost difference between the methods was small (€4·60 per week for alcohol-based handrub compared with €3·30 for soap and water).

Conclusion

There was no statistically or clinically significant difference in SSI rates, probably because more important factors contribute to SSI development. However, this study demonstrated the feasibility and affordability of alcohol-based handrubs for hand preparation before surgery in settings without continuous, clean water. Registration number: NCT00987402 (http://www.clinicaltrials.gov).

Preventing surgical site infections

The risk of surgical site infection (SSI) is approximately 1-3% for elective clean surgery. Apart from patient endogenous factors, the role of external risk factors in the pathogenesis of SSI is well recognized. However, among the many measures to prevent SSI, only some are based on strong evidence, for example, adequate perioperative administration of prophylactic antibiotics, and there is insufficient evidence to show whether one method is superior to any other. This highlights the need for a multimodal approach involving active post-discharge surveillance, as well as measures at every step of the care process, ranging from the operating theater to postoperative care. Multicenter or supranational intervention programs based on evidence-based guidelines, 'bundles' or safety checklists are likely to be beneficial on a global scale. Although theoretically reducible to zero, the maximal realistic extent by which SSI can be decreased remains unknown.