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Meta-Analysis
. 2016 Jan 22;2016(1):CD004288.
doi: 10.1002/14651858.CD004288.pub3.

Surgical hand antisepsis to reduce surgical site infection

Judith Tanner  1 , Jo C Dumville, Gill Norman, Mathew Fortnam
Affiliations
Meta-Analysis

Surgical hand antisepsis to reduce surgical site infection

Judith Tanner et al. Cochrane Database Syst Rev. .

Abstract

Background: Medical professionals routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient micro-organisms and inhibit the growth of resident micro-organisms. Antisepsis may reduce the risk of surgical site infections (SSIs) in patients.

Objectives: To assess the effects of surgical hand antisepsis on preventing surgical site infections (SSIs) in patients treated in any setting. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team.

Search methods: In June 2015 for this update, we searched: The Cochrane Wounds Group Specialized Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations) and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

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

Data collection and analysis: Three authors independently assessed studies for inclusion and trial quality and extracted data.

Main results: Fourteen trials were included in the updated review. Four trials reported the primary outcome, rates of SSIs, while 10 trials reported number of CFUs but not SSI rates. In general studies were small, and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. SSIsOne study randomised 3317 participants to basic hand hygiene (soap and water) versus an alcohol rub plus additional hydrogen peroxide. There was no clear evidence of a difference in the risk of SSI (risk ratio (RR) 0.97, 95% CI 0.77 to 1.23, moderate quality evidence downgraded for imprecision).One study (500 participants) compared alcohol-only rub versus an aqueous scrub and found no clear evidence of a difference in the risk of SSI (RR 0.56, 95% CI 0.23 to 1.34, very low quality evidence downgraded for imprecision and risk of bias).One study (4387 participants) compared alcohol rubs with additional active ingredients versus aqueous scrubs and found no clear evidence of a difference in SSI (RR 1.02, 95% CI 0.70 to 1.48, low quality evidence downgraded for imprecision and risk of bias).One study (100 participants) compared an alcohol rub with an additional ingredient versus an aqueous scrub with a brush and found no evidence of a difference in SSI (RR 0.50, 95% CI 0.05 to 5.34, low quality evidence downgraded for imprecision). CFUsThe review presents results for a number of comparisons; key findings include the following.Four studies compared different aqueous scrubs in reducing CFUs on hands.Three studies found chlorhexidine gluconate scrubs resulted in fewer CFUs than povidone iodine scrubs immediately after scrubbing, 2 hours after the initial scrub and 2 hours after subsequent scrubbing. All evidence was low or very low quality, with downgrading typically for imprecision and indirectness of outcome. One trial comparing a chlorhexidine gluconate scrub versus a povidone iodine plus triclosan scrub found no clear evidence of a difference-this was very low quality evidence (downgraded for risk of bias, imprecision and indirectness of outcome).Four studies compared aqueous scrubs versus alcohol rubs containing additional active ingredients and reported CFUs. In three comparisons there was evidence of fewer CFUs after using alcohol rubs with additional active ingredients (moderate or very low quality evidence downgraded for imprecision and indirectness of outcome). Evidence from one study suggested that an aqueous scrub was more effective in reducing CFUs than an alcohol rub containing additional ingredients, but this was very low quality evidence downgraded for imprecision and indirectness of outcome.Evidence for the effectiveness of different scrub durations varied. Four studies compared the effect of different durations of scrubs and rubs on the number of CFUs on hands. There was evidence that a 3 minute scrub reduced the number of CFUs compared with a 2 minute scrub (very low quality evidence downgraded for imprecision and indirectness of outcome). Data on other comparisons were not consistent, and interpretation was difficult. All further evidence was low or very low quality (typically downgraded for imprecision and indirectness).One study compared the effectiveness of using nail brushes and nail picks under running water prior to a chlorhexidine scrub on the number of CFUs on hands. It was unclear whether there was a difference in the effectiveness of these different techniques in terms of the number of CFUs remaining on hands (very low quality evidence downgraded due to imprecision and indirectness).

Authors' conclusions: There is no firm evidence that one type of hand antisepsis is better than another in reducing SSIs. Chlorhexidine gluconate scrubs may reduce the number of CFUs on hands compared with povidone iodine scrubs; however, the clinical relevance of this surrogate outcome is unclear. Alcohol rubs with additional antiseptic ingredients may reduce CFUs compared with aqueous scrubs. With regard to duration of hand antisepsis, a 3 minute initial scrub reduced CFUs on the hand compared with a 2 minute scrub, but this was very low quality evidence, and findings about a longer initial scrub and subsequent scrub durations are not consistent. It is unclear whether nail picks and brushes have a differential impact on the number of CFUs remaining on the hand. Generally, almost all evidence available to inform decisions about hand antisepsis approaches that were explored here were informed by low or very low quality evidence.

PubMed Disclaimer

Conflict of interest statement

Judith Tanner:

Judith Tanner gave a lecture at two study days in 2013 for which her employer was paid an honorarium from Molnlycke HealthCare. Judith Tanner had no control of the funds. Molnlycke Healthcare produce a surgical hand antiseptic solution.

Judith Tanner gave a lecture at a study day in 2015 for which she was paid an honorarium from Molnlycke HealthCare. This money was later forwarded to her employer and Judith Tanner has no control of the funds. Molnlycke Healthcare produce a surgical hand antiseptic solution.

Judith Tanner gave a lecture at a study day in 2015 for which she was paid an honorarium from Smith and Nephew. Smith and Nephew do not make any products relevant to this review.

Jo Dumville: none known.

Gill Norman: my employment at the University of Manchester is funded by NIHR Cochrane programme Grant 13/89/08‐ High Priority Cochrane Reviews in Wound Prevention and Treatment.

Matthew Fortnam: none known.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 basic hand hygiene versus alcohol rub, Outcome 1 SSI.
2.1
2.1. Analysis
Comparison 2 chlorhexidine versus iodine, Outcome 1 CFUs.
3.1
3.1. Analysis
Comparison 3 chlorhexidine versus iodine plus triclosan, Outcome 1 CFUs.
4.1
4.1. Analysis
Comparison 4 alcohol rub versus other alcohol rub, Outcome 1 CFUs.
5.1
5.1. Analysis
Comparison 5 scrub versus alcohol‐only rub, Outcome 1 SSI.
6.1
6.1. Analysis
Comparison 6 scrub versus alcohol rub, Outcome 1 SSI.
7.1
7.1. Analysis
Comparison 7 scrub (chlorhexidine) versus alcohol rub + additional ingredient, Outcome 1 CFUs.
8.1
8.1. Analysis
Comparison 8 scrub (povidone iodine) versus alcohol rub + additional ingredient, Outcome 1 CFUs.
9.1
9.1. Analysis
Comparison 9 scrub (chlorhexidine) versus rub + additional ingredient, Outcome 1 CFUs.
10.1
10.1. Analysis
Comparison 10 scrub (chlorhexidine) versus alcohol rub + additional ingredient, Outcome 1 CFUs.
11.1
11.1. Analysis
Comparison 11 duration ‐ Kappstein (5 minutes versus 3 minutes), Outcome 1 CFUs immediately after antisepsis.
12.1
12.1. Analysis
Comparison 12 duration ‐ 5 + 3 min versus 3 + 0.5 min with chlorhexidine), Outcome 1 CFUs.
13.1
13.1. Analysis
Comparison 13 duration ‐ 5 + 3 min versus 3 + 0.5 minutes with iodine), Outcome 1 CFUs.
14.1
14.1. Analysis
Comparison 14 duration ‐ 5 + 3.5 min versus 3 + 2.5 min chlorhexidine), Outcome 1 CFUs.
15.1
15.1. Analysis
Comparison 15 scrub versus scrub plus brush, Outcome 1 CFUS.
16.1
16.1. Analysis
Comparison 16 scrub versus scrub plus nail pick, Outcome 1 CFUs.
17.1
17.1. Analysis
Comparison 17 scrub plus brush versus scrub plus nail pick, Outcome 1 CFUs.
See this image and copyright information in PMC

Update of

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References to studies awaiting assessment

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References to other published versions of this review

Tanner 2003
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