Anda di halaman 1dari 8

Antibacterial Efficacy of Several Surgical Hand Preparation

Products Used by Veterinary Students


Po-Yen Chou1, Aimie J. Doyle2, Shiori Arai1, Pierre J. Burke1, and Trina R. Bailey1
Departments of 1Companion Animal and 2Health Management, Atlantic Veterinary Medicine, Charlottetown, Prince Edward Island, Canada

Corresponding Author Objective: To compare the antibacterial efficacy of different surgical hand antisepsis
Po-Yen Chou protocols used by veterinary students.
Department of Surgical and Radiological Study Design: Prospective, randomized, controlled study.
Sciences Study Population: Third year veterinary students (n545).
School of Veterinary Medicine
Methods: The participants were randomly assigned to 4 of the following 12 hand
University of California-Davis
preparation product/time combinations: nonabrasive hand scrub method with 4%
One Shields Road
Davis, CA 95616 chlorhexidine gluconate (CH); hand rub with a mixture of 30% 1-propanol and 45%
choudon@gmail.com 2-propanol solution (MPS), 70% 2-propanol solution (IPS), or 61% ethanol solution
with 1% chlorhexidine gluconate (ES/CH), with a contact time of 1.5, 3, or 5 minutes.
Submitted February 2015 Antibacterial efficacy was assessed after surgical hand preparation and at the end of
Accepted July 2015 surgery. Log reductions of total bacterial colony forming unit (CFU)/mL and positive
aerobic culture rates were compared using multivariable analysis of variance and mul-
DOI:10.1111/vsu.12473 tivariable logistic regression, respectively.
Results: After surgical hand preparation, CH and ES/CH provided significantly higher
log CFU reduction and lower positive culture rate for Gram-positive and spore-
forming bacteria compared to MPS and IPS. Increase in contact time did not provide
significant improvement in bacterial reduction. At the end of surgery, ES/CH provided
significantly higher log CFU reduction compared to IPS and lower positive culture rate
for Gram-positive bacteria compared to CH, MPS, and IPS. Increase in contact time
significantly improved log CFU reduction in ES/CH and MPS groups.
Conclusion: In our population of veterinary students ES/CH hand rubs or CH scrubs
were more effective in reducing bacterial CFU during surgical hand preparation than
MPS or IPS.

Surgical site infection (SSI) is a major postoperative compli- mended scrub time for CH has decreased from 10 to 5
cation in both human and veterinary medicine, leading to minutes. In addition, the use of brushes is no longer recom-
delayed wound healing, prolonged hospital stays, increased mended, because of reported skin irritations and micro-
use of antibiotics, increased medical costs, and potentially abrasions, increased bacterial colonization,7,8 poor compli-
fatal outcomes.1,2 Unintentional transfer of microorganisms ance,9 excessive water use, and solid waste production.10
to patients during surgery is a cause for SSI. While wearing ABR products contain short-chain alcohols as the pri-
sterile gloves helps prevent transfer of microorganisms from mary active ingredient, most commonly isopropanol and
the hands of surgical team members to the patient, glove per- ethanol. Long-acting compounds such as chlorhexidine glu-
foration is a common occurrence. In a recent study, at least conate or quaternary ammonium compounds may also be
one glove became defective in 26.2% of surgical procedures included in the formula. Use of ABR resulted in reduced
in a small animal referral hospital and only 30.8% of the preparation time, cost, and water usage,10 and ABR products
glove punctures were noted by the wearer.3 Therefore, proper have been reported to be at least as effective as CH.11
surgical hand preparation is still regarded as an important step Although frequently marketed as waterless hand scrub, an ini-
for prevention of SSI.1,2,4 Surgical hand preparation methods tial hand wash is recommended by WHO to help remove any
have evolved gradually since Joseph Lister first demonstrated soil, blood, and bacterial spores before application of
the efficacy of carbolic acid for skin disinfection in 1867.5 ABR.6–13
Currently, aqueous scrub with 4% chlorhexidine deter- The recommended contact time for surgical hand prepa-
gent (CH) and alcohol-based hand rubs (ABR) are both rec- ration using a mixture of 30% 1-propanol and 45% 2-
R
ommended by the World Health Organization (WHO) for propanol solution (MPS; SteriliumV, BODE Chemie GmbH
surgical hand preparation.6 Over the last decades, the recom- & Co. KG, Hamburg, Germany) and 70% 2-propanol solu-
R
tion (IPS; ManorapidV, Antiseptica Chem Pharm Produkte
Presented in part at the ACVS Surgery Summit, San Antonio, GmbH, Pulheim, Germany) were 1.5 and 3 minutes, respec-
TX, October 2014. tively.8 A contact time of 1.5 minutes was also recommended

Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons 515
Efficacy of Alcohol-Based Surgical Hand Preparations Chou et al.

for a different product containing 61% ethanol solution with digital spaces, hands, and forearms. (3) Scrub using the
R
1% chlorhexidine gluconate (ES/CH; AvagardV, 3M, St. sponge side only to clean nails, cuticles, interdigital spaces
Paul, MN). Because of different recommended application hands, and forearms. (4) When the assigned contact time is
methods and contact times,6,14 ABR may be more prone to reached, rinse hands and forearms thoroughly with tap water
errors than CH scrub.8 To help prevent confusion, WHO pro- and dry with a sterile towel before putting on surgical gloves
posed a standard application method and suggested following and gown.
the contact time recommended by the manufacturer.6 The hand rubbing procedure (MPS, IPS, or ES/CH) was
ABR are used infrequently by veterinary surgeons, with performed as follows: (1) Wash hands and arms with a neu-
R
79.9% of veterinary surgeons still only using disinfectant tral, non-medicated soap (DermotanV, Antiseptica Chem
soap/scrub for surgical hand preparation.15 With the increas- Pharm Produkte GmbH, Pulheim, Germany) for 1 minute and
ing acceptance of surgical hand rubs, it is crucial for veteri- use nail picks to clean under the fingernails. (2) Dry hands
narians to be familiar with the techniques and for a good with nonsterile paper towel. (3) Start timing. Put approxi-
standard of practice to be established in veterinary medicine. mately 5 mL (MPS or IPA) or 1 pump (ES/CH) in the palm
However, most veterinary schools in North America do not of the left hand. Dip the fingers of right hand in the hand rubs
provide training in proper ABR application in the curriculum. to decontaminate under the nails. Smear the hand rub on the
Before instituting surgical hand rubs in an educational setting, right forearm up to the elbow. (4) Repeat the process by put-
the efficacy of ABR and the effect of extended contact time ting the selected solution in the palm of the right hand and
must be further evaluated. dipping the fingers of left hand and smear on the left forearm
The purpose of this study was to evaluate the antimicro- up to the elbow. (5) Put approximately 5 mL (MPS or IPS) or
bial effect of 4 hand preparation products (CH, MPS, IPS, 1 pump (ES/CH) in the palm of the left hand. (6) Cover the
and ES/CH) at recommended and extended contact times in a whole surface of both hands up to the wrist with solution,
group of third year veterinary students. We hypothesized that rubbing palm against palm with a rotational movement. (7)
at manufacturer-recommended application times, commercial Rub the hands using the following orders: back of hand with
surgical hand rubs would reduce bacterial numbers as effec- opposite palm, palms and interdigital area with fingers inter-
tively as the nonabrasive CH hand scrub technique in veteri- linked, the back of the fingers, thumbs. Use more solution if
nary students, and increased contact time of surgical hand necessary. (8) Repeat steps 5–7 until the assigned contact
preparations would provide additional reduction in bacterial time is reached. (9) Wait until the hands are dry before putting
counts. on surgical gloves and gown.

Sample Collection
MATERIALS AND METHODS
Samples were obtained from participants using a glove juice
This research was approved by University of Prince Edward technique as previously described.15 All participants donned
R

Island Research Ethics Board. A controlled, randomized, pro- sterile gloves (TriflexV, Cardinal Health, McGaw Park, IL);
spective study was performed. Third year veterinary students then, 20 mL 0.075 mol/L phosphate-buffered normal saline
attending weekly junior surgery laboratory were included in with 0.05% Tween 80 was immediately instilled inside the
the study. Written consent was obtained from all participants dominant hand glove sterilely and the solution was rubbed up
before the study. and down the fingers of the glove. Next, participants clenched
Hand washing procedures included nonabrasive hand their fists and shook their hands for 60 seconds, with their fin-
scrub with CH and hand rubbing using MPS, IPS, or ES/CH. gers pointing down to keep the fluid within the glove. The
Each procedure was carried out at 3 different contact times gloves on both hands were removed carefully without con-
(1.5, 3, and 5 minutes) for a total of 12 possible procedure/ taminating the participant’s hands and forearms and 5–10 mL
time combinations. Using shuffled cards, participants were of the liquid retained within the glove was removed sterilely
randomly assigned to 4 of the possible 12 combinations. using a syringe. Samples were collected before (PRE) and
Detailed practical guidance on the steps of surgical hand after surgical hand preparation (POST). After POST sam-
preparation was given to all participants by the primary inves- pling, the participant then used a sterile towel to dry their
tigator and posted next to the scrub sink in accordance with hands, and gowned and gloved to perform ovariohysterec-
current practice standards and WHO guidelines.6 Contact tomy (OHE) or castration on live animals using standard
time was defined as the time hands and forearms were in con- aseptic techniques. Samples were collected again from the
tact with the tested products. gloves of the participants at the end of surgery (END). All
gloves used for sample collection in this study were tested for
Hand Preparation Procedures the presence of punctures by insufflation and visual control.
Individual sample sets (PRE, POST, and END) were excluded
The hand scrubbing procedure (CH) was performed in the if contamination that required glove change occurred, if the
following sequence: (1) Wet hands and forearms with warm glove failed the puncture test, if the participant did not pro-
tap water and use nail picks to clean under the fingernails. (2) vide samples for culture at all 3 collection time points, or if
Start timing, wet the sponge, and squeeze to work up a lather, participants had a visible full thickness wound on their hands.
making sure the lather is in contact with nails, cuticles, inter- Individual participants were excluded if allergic reaction to

516 Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons
Chou et al. Efficacy of Alcohol-Based Surgical Hand Preparations

the researched products or latex developed during the RESULTS


research period. A minimum 7-day wash out period between
hand treatments was enforced to allow regrowth of the normal Forty-seven third year veterinary students were enrolled into
skin flora, as previously described.16 the study. Data of 2 participants were excluded from analysis
because of allergic reactions to the chlorhexidine products. In
Aerobic Culture, CFU Count, and Bacterial Isolation addition, 25 sample sets were excluded (9 because of contam-
ination during surgery, 8 because of removal of surgical glove
Samples collected were immediately cultured. Each sample before sample collection, and 9 because of glove perforation
was diluted by 2 serial 10-fold dilutions using 0.075 mol/L detected by the pressure test). A total of 155 sample sets
phosphate buffered saline with 0.05% Tween 80 and 100 lL (PRE, POST, and END) from 45 students were included in
of each undiluted and serially diluted solution was inoculated the final bacterial analysis. Out of the 95 surgeries performed,
onto sheep blood agar plates using sterile spreaders. The agar 76 were OHE and 19 were castrations. Surgery time ranged
plates were then incubated for 48 hours at 358C under aerobic from 57 to 255 minutes (median 136 minutes). SSI was docu-
conditions. Bacterial colony forming units (CFU)/mL was mented in 1 dog that underwent OHE. The infection was
calculated using direct counting methods with a range from 0 caused by S. pseudintermedius. This bacterial isolate was not
to 300. Plates that yielded growth of >300 colonies were cultured from the hands of either the primary or the assistant
excluded for CFU determination and individual colony isola- student.
tion.17,18 Bacterial colonies on all agar plates were manually
counted by the primary investigator with no repetition. Bacte- Aerobic Bacterial Reduction
rial log CFU (logCFU) were determined and reduction in
logCFU from the glove juice at each sampling time point Hand preparation product, but not contact time, significantly
(POST and END) were calculated by subtracting the POST or affected POST logCFU reduction (P<.001; Fig 1). At the
END logCFU from the PRE logCFU. manufacturer recommended contact times (MPS: 1.5 minute;
Based on gross appearance, individual colonies were fur- IPS 3 minutes; ES/CH 1.5 min; CH: 5 minutes), ES/CH and
ther subcultured onto a sheep blood agar plate and incubated CH were more effective at reducing logCFU compared to
for 24 hours at 358C under aerobic conditions. Bacterial colo- MPS or IPS.
nies were then identified using matrix-assisted laser desorp- For END samples, hand preparation product (P<.001),
tion ionization-time of flight mass spectrometry (MALDI contact time (P5.023), and product/contact time interaction
Biotyper system, Bruker Corporation, Billerica, MA) and (P5.042) had significant effects on bacteria logCFU reduc-
categorized as Gram-positive, Gram-negative, spore-forming tion (Fig 2). Role in surgery (primary or assistant) and type of
bacteria, and coagulase-positive Staphylococcus spp. surgery (OHE or castration) did not have significant effects
on bacterial reduction (P5.667 and P5.619, respectively).
Bacterial reduction in ES/CH and MPS groups was signifi-
Statistical Analysis
cantly increased by increasing contact time (P5.003 and
The POST and END bacterial logCFU reduction between P5.014, respectively). At the manufacturer recommended
groups were compared with a multivariable analysis of var- contact time, the ES/CH group had a significantly higher
iance model. Hand preparation product, contact time, and logCFU reduction compared to IPS (P5.024).
product/contact time interaction were included as variables in
the models, with the participants included as random effect. Aerobic Bacterial Isolation (Table 1)
Surgery time, type of surgery (OHE or castration), and role in
One hundred fifteen species of 34 different genera of bacteria
surgery (primary or assistant) were included as variables for
were isolated. The most commonly isolated Gram-Positive,
END logCFU reduction. Stepwise backward elimination was
Gram-negative, and spore-forming bacteria in the samples
performed to remove non-significant effects. A post hoc anal-
were Staphylococcus spp, Moraxella spp, and Bacillus spp,
ysis was performed with Tukey’s honestly significant differ-
respectively.
ence tests and “test slices” were used to test effect of time for
For both POST and END samples, the positive culture
each product.16 For each bacterial category, the culture status
rate for coagulase-positive Staphylococcus spp. and Gram-
was classified as either positive or negative. The positive cul-
negative bacteria were too low to allow a meaningful multi-
ture status between groups was compared using a multivari-
variable statistical analysis.
able logistic regression model. Product, contact time, and
product/contact time interaction were used as main factors
Gram-Positive Aerobic Bacteria
and culture status from PRE samples was included as a
cofounding factor. For END samples, surgery type (OHE or For POST samples, hand preparation product, but not contact
castration), and role in surgery (primary or assistant) were fur- time and PRE culture status had a significant effect on posi-
ther included in the model. Stepwise backward elimination tive culture rate (P<.001). Estimated positive culture rates for
was performed. P.05 was considered statistically significant the 4 products were ES/CH (11.9%), CH (18.4%), MPS
for all analyses. All statistics were performed using commer- (70.6%), and IPS (95.1%). ES/CH and CH groups each had a
R
cial statistics software (JMP 11V, SAS system, Cary, NC). significantly lower positive culture rate compared to MPS and

Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons 517
Efficacy of Alcohol-Based Surgical Hand Preparations Chou et al.

Figure 1 Mean (6 SD) logCFU reduction immediately after surgical hand preparation (POST) using different products (CH [4% chlorhexidine
gluconate scrub], MPS [30% 1-propanol and 45% 2-propanol solution], IPS [70% 2-propanol solution], ES/CH [61% ethanol solution with 1% chlor-
hexidine gluconate]) with different contact times (1.5, 3, 5 minutes). Values with different lowercase letters (a,b,c) next to the column are signifi-
cantly different.

Figure 2 Mean (6 SD) logCFU reduction at the end of surgery (END) using different hand preparation products (CH [4% chlorhexidine gluconate
scrub], MPS [30% 1-propanol and 45% 2-propanol solution], IPS [70% 2-propanol solution], ES/CH [61% ethanol solution with 1% chlorhexidine glu-
conate]) with different contact times (1.5, 3, 5 minutes). Values with different lowercase letters next to the column (a,b,c,d) are significantly
different.

518 Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons
Chou et al. Efficacy of Alcohol-Based Surgical Hand Preparations

IPS groups (P<.001). MPS groups had a significant lower cant positive and negative association with culture status,
positive culture rate compare to IPS groups (P5.003). respectively. When surgery time is fixed at 150 minutes, the
For END samples, both hand preparation product and predicative positive culture rates for aerobic spore-forming
PRE culture status had a significant effect on positive culture bacteria at different contact times were: 1.5 minutes (22.5%);
(P<.001 and P5.009, respectively). Estimated positive cul- 3 minutes (21.4%); and 5 minutes (6.4%). Contact time at 5
ture rates of the 4 products were: ES/CH (41.5%), CH minutes had a significantly higher positive culture rate com-
(75.7%), IPS (87.8%), and MPS (78.8%). ES/CH groups had pared to 1.5 minutes and 3 minutes (P5.022 and P5.028,
a significantly lower positive culture rate compared to CH, respectively). The longer the surgery time (per hour), the
MPS, and IPS groups (P5.002, P<.001, and P5.001, respec- more likely an aerobic spore-forming bacteria was isolated
tively). No significant differences were detected between CH, (odds ratio, 2.561; 95% CI, 1.301–5.345).
MPS, and IPS groups.

DISCUSSION
Spore-Forming Aerobic Bacteria
For POST samples, hand preparation products had a signifi- At manufacturer recommended contact times, ES/CH and CH
cant effect on positive culture result (P<.001). The predictive provided significantly higher bacterial reduction compared to
positive culture rates for aerobic spore-forming bacteria were: MPS and IPS immediately after surgical hand preparation. At
ES/CH (4.8%), CH (15.8%), IPS (90.2%), and MPS (73.5%). the end of surgery, ES/CH still had significantly higher bacte-
ES/CH and CH groups had significantly lower positive cul- rial reduction compare to IPS.
tures compared to MPS and IPS groups (P<.001). These results may be due to several reasons. First, although
For END samples, hand preparation product did not the participants were instructed in proper hand rubbing techni-
have a significant effect on positive culture result (P50.19). ques before application and observed during the application pro-
Surgery time (P5.006) and contact time (P5.039) had signifi- cess, students may have remained unfamiliar with the technique.

Table 1 Positive culture rate for gram-positive, gram-negative, and spore-forming bacteria, and coagulase-positive Staphylococcus spp using differ-
ent surgical hand preparation methods.

Gram-positive Spore-forming Coagulase-positive Gram-negative


bacteria (%) bacteria (%) Staphylococcus bacteria (%)
95% CI 95% CI spp. (%) 95% CI 95% CI
Hand preparation
method PRE POST END PRE POST END PRE POST END PRE POST END

ES/CH1.5 100 20 73 67 13 7 0 0 0 40 0 0
80–100 7–45* 48–89† 42–85 4–38‡ 1–30 0–20 0–20 0–20 20–64 0–20 0–20
ES/CH3 92 8 23 62 0 8 8 0 0 31 0 0
67–98 1–33* 8–50† 36–82 0–23‡ 1–33 1–33 0–23 0–23 13–58 0–23 0–23
ES/CH5 100 7 21 64 0 0 7 0 0 7 0 0
78–100 1–31* 8–48† 39–84 0–22‡ 0–22 1–31 0–22 0–22 1–31 0–22 0–22
CH1.5 100 23 69 46 15 8 8 8 0 15 0 0
77–100 8–50* 42–87 23–71 4–42‡ 1–33 1–33 1–33 0–23 4–42 0–23 0–23
CH3 100 15 85 62 30 15 15 8 8 31 0 0
77–100 4–42* 58–96 36–82 13–58‡ 4–42 4–42 1–33 1–33 13–58 0–23 0–23
CH5 92 17 6 50 0 17 25 8 8 25 0 8
65–99 5–45* 39–86 25–75 0–24‡ 5–45 9–53 1–35 1–35 9–53 0–24 1–35
IPS1.5 100 100 90 55 91 27 0 0 9 27 0 0
74–100 74–100 16–38 28–79 62–98 10–57 0–26 0–26 2–38 10–57 0–26 0–26
IPS3 100 87 80 60 87 33 7 0 7 1 0 0
79–100 62–96 55–93 36–80 62–96 15–58 1–30 0–20 1–30 4–38 0–20 0–20
IPS5 100 100 93 60 93 7 20 0 7 27 0 0
80–100 80–100 70–99 36–80 70–99 1–30 7–45 0–20 1–30 11–89 0–20 0–20
MPS1.5 100 83 67 67 75 42 42 17 0 33 33 0
76–100 55–95§ 40–86 39–86 47–91 19–68 19–68 47–91 0–24 14–61 14–61 0–24
MPS3 100 82 91 55 82 18 27 0 0 9 0 0
74–100 52–95§ 62–98 28–79 52–95 5–48 10–57 0–26 0–26 2–38 0–26 0–26
MPS5 91 45 72 55 64 9 9 0 0 0 0 0
62–98 21–72§ 43–90 28–79 35–85 2–38 2–38 74–100 0–26 0–26 0–26 0–26

CH [4% chlorhexidine gluconate scrub]; ES/CH [61% ethanol solution with 1% chlorhexidine gluconate]; MPS [30% 1-propanol and 45% 2-propanol
solution]; IPS [70% 2-propanol solution]; PRE, before surgical hand preparation; POST, after surgical hand preparation; END, at the end of surgery.
*,‡ indicate significantly lower culture rates compared to MPS and IPS.

indicates significantly lower culture rates compared to CH, MPS, and IPS (P<.001).
§
indicates significantly lower culture rates compared to IPS.

Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons 519
Efficacy of Alcohol-Based Surgical Hand Preparations Chou et al.

Compared to ES/CH, IPS and MPS evaporate very rapidly, lar selective culture process, as such differences were not
making it possible that missed contact areas may be unnoticed observed in the END samples. It is possible the spore-
during application. One study has shown that when using an forming bacteria were present but were not isolated as com-
ABR product with an active ingredient similar to IPS for hand monly in the END samples because of overall increased bac-
sanitization, additional training improves bacterial reduction and teria colonies on the agar plate. To the authors’ knowledge,
decreases the incidence of missed contact areas.19 A signifi- this is the first study that demonstrates a difference in culture
cantly different antibacterial efficacy also exists between medi- rate for spore-forming bacteria after surgical hand preparation
cal students in the first two academic years compared to the last using pure alcohol rubs (MPS and IPS). The spore-forming
two academic years.20 The question of whether the use of ES/ bacteria isolated in our study were of low virulence and are
CH helps to decrease missing contact spots or if additional train- rarely cultured from infected wounds. Nonetheless, this find-
ing helps to improve the efficacy of ABR for surgical hand prep- ing should be taken into consideration when choosing surgi-
aration would require more investigation. cal hand rubs for immune compromised animals and for
A second possible explanation for the results found in surgeries where infection would be catastrophic, such as
our study is that the moisture retained on hands after washing internal fixation or joint replacement.
and drying may impair the efficacy of ABR by decreasing the One SSI occurred during the study period. The S. pseu-
alcohol concentrations on the skin. The bacteriostatic and dintermedius isolated from the incision is a pathogenic bacte-
bacteriocidal concentrations for chlorhexidine are 1 and 20 ria that colonizes canine skin and was not cultured from
lg/mL, respectively.11 In our study, even with some retained either the surgeon or the assistant, suggesting that the infec-
moisture, the concentration of chlorhexidine on hands may tion may be from a source other than residue hand bacteria.
still be above 1 lg/mL and, therefore, residual antibacterial The exact relationship between bacterial burden on surgeons’
activity persists. Controversies remain in human medicine as hands and infection rate remains unknown. Several human
to whether or not hand washing before ABR application is studies have reported that in modern surgery environments,
necessary.6,21 However, because of the different nature of there was no significant difference in SSI rate when ABR
practice in veterinary medicine, washing hands before ABR were used in comparison with plain soap hand wash and chlo-
application may still be desired. rhexidine scrubs.28–30 Another study showed glove perfora-
A third possible explanation for the results found in our tion significantly increased infection rate if no antimicrobial
study is that glycerol is commonly used in hand care products prophylaxis was given.31 These studies reiterate the concept
and it may have altered the efficacy of IPS and MPS, since it that SSI is a multifactorial complication. Surgery type, sur-
has been shown to decrease the efficacy of pure alcohol hand geon and patient preparation, operation room behavior, and
rubs.13 All participants were asked to wash their hands with a tissue trauma are important variables for SSI. Similar research
neutral soap for at least 1 minute or until their hands were free is lacking in veterinary medicine and would require a large
of organic matter. Unfortunately, glycerol within hand care scale, multi-institutional study. Such work is needed to help
products may be hard to remove by a single hand wash.22 elucidate the clinical benefit of different presurgical hand
In a previous report, no difference in bacterial reduction antisepsis protocols in veterinary patients.
was detected between 1.5 and 3 minute application times of Several limitations in our study are noteworthy. First, the
MPS in healthy volunteers.14 Contact time up to 5 minutes participants and authors were not blinded to specific products
with ABR has not been evaluated before, since one of the used and contact time. Second, only sheep blood agar plates
claimed benefits for ABR is shorter application time. In the were used for culture. The use of MacConkey agar plates
present study, increase in contact time did not help improve would have allowed for the identification of a greater spectrum
bacterial reduction immediately after surgical hand prepara- of Gram-negative bacteria. Third, the average duration of sur-
tion, but it significantly improved bacterial reduction of ES/ gery in our study was relatively short and no cumulative effects
CH and MPS at the end of surgery. An increased amount of were tested. Thus, our data should be interpreted with caution
product would be necessary to achieve longer contact times for surgeries of longer duration and for clinical settings where
and the repeated rubbing process may have helped decrease repeated surgical hand preparations are performed throughout
missing spots and improved antibacterial efficacy.17 Nonethe- a single day. Lastly, neutralizing agents for chlorhexidine were
less, this additional bacterial reduction was only observed at not added to any of the samples. Controversy persists whether
the end of surgery and the evaluation of possible clinical ben- residual neutralizing agents on the skin will reduce the effec-
efits would require more research. Although ABR are tiveness of the surgical hand preparation or if the antimicrobial
regarded as relatively safe products, potential disadvantages activity of nonvolatile chlorhexidine would improve because
for using an increased amount may include dermal and respi- of a residue effect. Different neutralizers of unknown efficacies
ratory absorption of alcohol, irritation to the respiratory tract, added in different studies further complicate comparison of our
and possible fire hazard.23–25 results. The US Food and Drug Administration has not pro-
The recovery rate of spore-forming bacteria, such as vided clear guidelines as to whether neutralizing agents should
Bacillus spp and Paenibacillus spp, increased after MPS and be added or not, but has recommended the clear indication of
IPS application at all 3 different contact times in the POST neutralization status in reports to facilitate the comparison of
samples. Alcohol has no sporicidal activity and ethanol has results across studies.34
even been used for selective isolation of spore-forming bacte- The optimal surgical hand preparation solution should be
ria.26,27 We suspect that our observation may be due to a simi- effective in removing transient bacteria and reducing bacteria

520 Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons
Chou et al. Efficacy of Alcohol-Based Surgical Hand Preparations

regrowth, cause minimal skin irritation, and generate the least because of hand hygiene procedures on the health care workers.
amount of waste. In our study, using both alcohol-based and Am J Infect Control 2009;37:155–159
non-alcohol-based solutions effectively reduced bacteria 8. Widmer AF: Surgical hand hygiene: scrub or rub? J Hosp Infect
counts at all product/time combinations. However, because of 2013;83:S35–S39
lower logCFU bacterial reductions after surgical hand prepa- 9. Anderson MEC, Foster BA, Weese JS: Observational study of
ration and at the end of surgery, as well as higher positive cul- patient and surgeon preoperative preparation in ten companion
ture rates observed, pure alcohol products such as MPS and animal clinics in Ontario, Canada. BMC Vet Res 2013;9:194–205
IPS should be avoided in the population of subjects studied. 10. Cimiotti JP, Stone PW, Larson EL: A cost comparison of hand
The results of our study suggest that veterinary students hygiene regimens. Nurs Econ 2004;22:196–199
should use CH hand scrub or ES/CH rubs for surgical hand 11. Kampf G, Kramer A: Epidemiologic background of hand
preparation. These results may also prove pertinent for other hygiene and evaluation of the most important agents for scrubs
veterinary surgeons; however, further research is needed with and rubs. Clin Microbiol Rev 2004;17:863–893
the various surgical hand preparation products and procedures 12. Jabbar U, Leischner J, Kasper D, et al: Effectiveness of alcohol-
in other groups of people and patients to make meaningful based hand rubs for removal of Clostridium difficile spores from
comparisons and recommendations. hands. Infect Control Hosp Epidemiol 2010;31:565–570
13. Suchomel M, Rotter M, Weinlich M, et al: Glycerol significantly
decreases the three hour efficacy of alcohol-based surgical hand
ACKNOWLEDGMENTS rubs. J Hosp Infect 2013;83:284–287
14. Kampf G, Ostermeyer C, Heeg P: Surgical hand disinfection
This project was funded by the Atlantic Veterinary College Internal with a propanol-based hand rub: equivalence of shorter
application times. J Hosp Infect 2005;59:304–310
Research Fund. The research products tested were kindly supplied
by the manufacturers. We acknowledge Dr. Jeff Lewis, Ms. Beatrice 15. Verwilghen D, Grulke S, Kampf G: Presurgical hand antisepsis:
Hartinger, and Mr. Matt Saab for their assistance with bacteriology concepts and current habits of veterinary surgeons. Vet Surg
2011;40:515–521
methods, Dr. Henrik Styrn for his guidance in statistics, and Drs. J
McClure and Catherine Muckle for their help in manuscript 16. Suchomel M, Gnant G, Weinlich M, et al: Surgical hand
preparation. disinfection using alcohol: the effects of alcohol type, mode and
duration of application. J Hosp Infect 2009;71:228–233
17. Babb JR, Davies JG, Ayliffe G: A test procedure for evaluating
surgical hand disinfection. J Hosp Infect 1991;18:41–49
DISCLOSURE
18. Waterman TR, Smeak DD, Kowalski J, et al: Comparison of bacterial
counts in glove juice of surgeons wearing smooth band rings versus
The authors declare no conflicts of interest related to this those without rings. Am J Infect Control 2006;34:421–425
report.
19. Widmer AF, Conzelmann M, Tomic M, et al: Introducing
alcohol-based hand rub for hand hygiene: the critical need for
training. Infect Control Hosp Epidemiol 2007;28:50–54
REFERENCES
20. Tschudin SS, Frei R, Dangel M, et al: Effect of teaching
recommended World Health Organization technique on the use
1. Kirkland KB, Briggs JP, Trivette SL, et al: The impact of of alcohol-based hand rub by medical students. Infect Control
surgical-site infections in the 1990s: attributable mortality, Hosp Epidemiol 2010;31:1194–1195
excess length of hospitalization, and extra costs. Infect Control
21. Labadie JC, Kampf G, Lejeune B, et al: Recommendations for
Hosp Epidemiol 1999;20:725–730
surgical hand disinfection—requirements, implementation and
2. Nicoll C, Singh A, Weese JS: Economic impact of tibial plateau need for research. A proposal by representatives of the SFHH,
leveling osteotomy surgical site infection in dogs. Vet Surg 2014; DGHM and DGKH for a European discussion. J Hosp Infect
43:899–902 2002;51:312–315
3. Hayes GM, Reynolds D, Moens NM, et al: Investigation of 22. Suchomel M, Rotter M: Ethanol in pre-surgical hand rubs:
incidence and risk factors for surgical glove perforation in small concentration and duration of application for achieving
animal surgery. Vet Surg 2014;43:400–404 European Norm EN 12791. J Hosp Infect 2011;77:263–
4. Tanner J, Swarbrook S, Stuart J: Surgical hand antisepsis to 266
reduce surgical site infection. Cochrane Database Syst Rev 23. Bessonneau V, Thomas O: Assessment of exposure to alcohol
2008;1:CD004288 vapor from alcohol-based hand rubs. Int J Environ Res Public
5. Lister J: On the antiseptic principle in the practice of surgery. Health 2012;9:868–879
Lancet 1867;90:353–356 24. Bryant KA, Pearce J, Stover B: Flash fire associated with the use
6. World Health Organization Press: WHO Guidelines on Hand of alcohol-based antiseptic agent. Am J Infect Control 2002;30:
Hygiene in Health Care. Geneva, Switzerland, World Health 256–257
Organization, 2009 25. Turner P, Saeed B, Kelsey MC: Dermal absorption of isopropyl
7. Rocha LA: L Ferreira de Almeida e Borges, P Pinto Gontijo alcohol from a commercial hand rub: implications for its use in
Filho. Changes in hands microbiota associated with skin damage hand decontamination. J Hosp Infect 2004;56:287–290

Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons 521
Efficacy of Alcohol-Based Surgical Hand Preparations Chou et al.

26. Russell AD: Bacterial spores and chemical sporicidal agents. randomized equivalence study. J Am Med Assoc 2002;288:
Clin Microbiol Rev 1990;3:99–119 722–727
27. Koransky JR, Allen SD, Dowell VR: Use of ethanol for 31. Misteli H, Weber WP, Reck S, et al: Surgical glove perforation and
selective isolation of sporeforming microorganisms. Appl the risk of surgical site infection. Arch Surg 2009;144:553–558
Environ Microbiol 1978;35:762–765 32. Kampf G, Shaffer M, Hunte C: Insufficient neutralization in
28. Weight CJ, Lee MC, Palmer JS: Avagard hand antisepsis vs. testing a chlorhexidine-containing ethanol-based hand rub can
traditional scrub in 3600 pediatric urologic procedures. Urology result in a false positive efficacy assessment. BMC Infect Dis
2010;76:15–17 2005;5:48–53
29. Nthumba PM, Stepita-Poenaru E, Poenaru D, et al: Cluster- 33. Verwilghen DR, Mainil J, Mastrocicco E et al: Surgical
randomized, crossover trial of the efficacy of plain soap and hand antisepsis in veterinary practice: evaluation of soap scrubs
water versus alcohol-based rub for surgical hand preparation in a and alcohol based rub techniques. Vet J 2011;190:372–377
rural hospital in Kenya. Br J Surg 2010;97:1621–1628 34. United States Food and Drug Administration: Tentative
30. Parienti JJ, Thibon P, Heller R, et al: Hand-rubbing with an final monograph for healthcare antiseptic drug
aqueous alcoholic solution vs traditional surgical hand- products; proposed rule. Federal Register, 1994,
scrubbing and 30-day surgical site infection rates: a pp 31441–31452

522 Veterinary Surgery 45 (2016) 515–522 V


C Copyright 2016 by The American College of Veterinary Surgeons