The Veterinary Journal 190 (2011) 372–377

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The Veterinary Journal

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Surgical hand antisepsis in veterinary practice: Evaluation of soap scrubsand alcohol based rub techniques

Denis R. Verwilghen a,⇑, Jacques Mainil b, Emilie Mastrocicco a, Annick Hamaide c,Johann Detilleux d, Gaby van Galen a, Didier Serteyn a, Sigrid Grulke a

a Equine Clinic, Department of Clinical Sciences of Companion Animals and Equids, Faculty of Veterinary Medicine of Liege, Bld de Colonster 20 B41, 4000 Liege, Belgiumb Department of Infectious and Parasitic Diseases, Faculty of Veterinary Medicine of Liege, Bld de Colonster 20 B43, 4000 Liege, Belgiumc Small Animal Clinic, Department of Clinical Sciences of Companion Animals and Equids, Faculty of Veterinary Medicine of Liege, Bld de Colonster 20 B44, 4000 Liege, Belgiumd Department of Genetics and Biostatistics, Faculty of Veterinary Medicine of Liege, Bld de Colonster 20 B43, 4000 Liege, Belgium

a r t i c l e i n f o

Article history:Accepted 19 December 2010

Keywords:SurgeryHand asepsisVeterinaryDisinfectionRubScrub

1090-0233/$ - see front matter � 2010 Elsevier Ltd. Adoi:10.1016/j.tvjl.2010.12.020

⇑ Corresponding author. Present address: EquineMedicine, University of Agricultural Sciences, Ulls vägSweden. Tel.: +32 4 3664103.

E-mail addresses: denis@proamhorses.eu,(D.R. Verwilghen).

a b s t r a c t

Recent studies have shown that hydro-alcoholic solutions are more efficient than traditional medicatedsoaps in the pre-surgical hand antisepsis of human surgeons but there is little veterinary literature on thesubject. The aim of this study was to compare the efficiency of medicated soaps and a hydro-alcoholicsolution prior to surgery using an in-use testing method in a veterinary setting. A preliminary trialwas performed that compared the mean log10 number of bacterial colony forming units (CFU) and thereduction factors (RF) between two 5-min hand-scrubbing sessions using different soaps, namely, povi-done iodine (PVP) and chlorhexidine gluconate (CHX), and the 1.5-min application of a hydro-alcoholicrub.

A clinical in-use trial was then used to compare the hydro-alcoholic rub and CHX in a surgical setting.Sampling was performed using finger printing on agar plates. The hydro-alcoholic rub and CHX had asimilar immediate effect, although the sustained effect was significantly better for the hydro-alcoholicrub, while PVP had a significantly lower immediate and sustained effect. The hydro-alcoholic rub showedgood efficiency in the clinical trial and could be considered as a useful alternative method for veterinarysurgical hand antisepsis.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

The importance of hand hygiene was first recognized in 1847when a dramatic decrease in mortality rates occurred afterSemmelweis (1861) introduced hand scrubbing with chlorinatedlime solutions prior to every physical examination (Adriaanseet al., 2000). After recognition of the work of Lister (Tan and Tasaki,2007) towards the end of the 19th century, surgical hand antisepsiswas globally accepted. Soon after, Pasteur stated: ‘Instead of forcingourselves in trying to kill microbes in wounds, would it not be morereasonable not to introduce them’ (Wangensteen, 1975); a statementthat remains true today.

Surgical site infection (SSI) nevertheless continues to be one ofthe most frequent types of nosocomial infections (NNIS, 2003), de-spite the fact that pre-surgical antiseptic treatment of hands for

ll rights reserved.

Clinic, Faculty of Veterinary12, Box 7040, 750 07 Uppsala,

Denis.verwilghen@uds.slu.se

surgical staff has become mandatory. SSI is a primary factor in theincrease in human and veterinary health care costs due to delayedwound healing, increased use of antibiotics, increased hospital stayor even death of the patient (Plowman, 2000; Waguespack et al.,2006).

The risk of SSI correlates with the dose and the virulence ofmicrobial contamination and the patient resistance (Owens andStoessel, 2008). In normal situations, the risk of SSI is consideredelevated when the bacterial count in wounds is P105 bacteria/gof tissue (Hackett et al., 1983; Owens and Stoessel, 2008). Wearingof gloves by surgical staff significantly decreases surgical site con-tamination. However, glove perforation, principally occurring atthe index finger of the non-dominant hand, occurs in up to 67% ofsurgical interventions (Dodds et al., 1988; Eklund et al., 2002;Yinusa et al., 2004), highlighting the importance of correct handpreparation. The objective of surgical hand antisepsis is thereforeto eliminate or reduce skin flora prior to gloving to diminish the riskof SSI.

Three different types of surgical hand preparation methods areavailable, namely, traditional aqueous scrubs containing antisepticagents, alcohol-based rubs and alcohol-based rubs containing

D.R. Verwilghen et al. / The Veterinary Journal 190 (2011) 372–377 373

additional non-volatile active ingredients. Aqueous solutionscontaining either povidone iodine (PVP) or chlorhexidine gluco-nate (CHX) have become standard over the past few decades,although alcohol-based hand rubs (AHRs) have been used for over100 years (Kampf and Kramer, 2004). The popularity of AHRs isincreasing amongst physician surgeons because they provide rapidand immediate action, are considerably faster than disinfectingsoap scrubs and cause less skin damage after repeated use (Kampfand Kapella, 2003; Loffler and Kampf, 2008).

Veterinary patients are likely to have higher bacterial counts ontheir body surface than human patients, resulting in higher con-tamination loads on the hands of veterinary surgeons comparedto their human counterparts. Although the use of AHRs has beentested in studying the reduction in bacterial loads on the handsof veterinary staff between physical examinations of equine pa-tients (Traub-Dargatz et al., 2006), only evaluations or comparisonsof hand antisepsis techniques using aqueous solutions have beenused in veterinary-surgical setting studies to date (Wan et al.,1997; Waterman et al., 2006; Corder et al., 2007).

The aims of the present study were (1) to compare PVP and CHXscrubs with a hydro-alcoholic rub hand antisepsis protocol and (2)to evaluate the effectiveness of hydro-alcoholic rub solution inreducing bacterial hand flora in veterinary surgery. The hypothesiswas that an AHR solution would be at least as effective as currentlyused products and be acceptable to veterinary surgeons.

Materials and methods

Soaps

The following disinfecting soaps were tested: Chlorhexidine digluconate 4%(Hibiscrub, Regent Medical) and 7.5% PVP-iodine (Vetclean, Ecuphar). The handrub was 45% 2-propanol, 30% 1-propanol, 0.2% mecetronium ethylsulfate (Sterilli-um, Bode-Chemie).

Sampling method and bacterial evaluation

We used an in-use condition testing method, as described by Rotter et al. (2009)and used by Carro et al. (2007) and Kac et al. (2009) in-field tests. A blood agar madewith a Columbia Agar Base (Merck) was used to test bacterial contamination of thefingertips. All distal phalanges were gently pressed for 10 s onto two agar-contain-ing Petri plates (one for the left, one for the right hand). Bacterial growth was quan-tified by counting the colony forming units (CFU) grown after 24 h incubation at36 ± 1 �C.

Scrub technique

A 5-min scrubbing technique, using one of the above disinfecting soaps andsterile disposable brushes (Scrub care, CareFusion), was carried out. Sub-ungualareas were cleaned with a nail cleaner (disposable and delivered with the brushes).Special attention was paid to nails and palms. Hands and forearms, including theelbow, were washed with medicated soaps and dried with sterile disposable towelsprior to sampling and gloving.

Rub technique

The rubbing method followed the European standardisation norm prEN 12791(2005) and the company’s recommendations. Prior to application of the AHR, handswere washed for 1 min with a neutral soap (Baktolin basic, Bode Chemie) and sub-ungual areas were cleaned as described above. Hands were thoroughly dried usingnon-sterile paper, after which Sterillium was rubbed onto hands and forearm for1.5 min. Hands were sampled as described above and gloved after complete evap-oration of Sterillium.

Glove puncture test

All gloves used in this study were collected and tested for the presence of punc-tures by insufflations and visual control.

Preliminary study

This preliminary study was carried out by two surgeons experienced in handantisepsis techniques. Hands were sampled as described above prior to hand anti-sepsis (PHA), immediately after hand antisepsis (AHA) and 3 h after (after gloves,AG/sustained effect) wearing sterile non-powdered gloves (Triflex Select, CareFu-sion). Each product (PVP, CHX and AHR) was randomly used on separate days until10 samples series (one PHA, one AHA, one AG) were obtained for each surgeon andeach product tested (20 samples series per product). Samples containing puncturedgloves were excluded from testing.

Surgical study

A trial using Sterillium and CHX soap was carried out by three equine and twosmall animal surgeons during routine and emergency procedures. Hands were dis-infected using the rubbing method for Sterillium and scrubbing method for CHXsoap. Sampled were collected as described above, with the inclusion of a sample ta-ken immediately after the surgery (after surgery, AS/sustained effect) (= one seriesof samples). Hands were double gloved (both non-powdered). The first pair ofgloves (Protegrity SMT, CareFusion) was put on using a closed technique and cov-ered with a second pair (Triflex Select, CareFusion), which was discarded after drap-ing the patient. For some procedures, a new second pair was put on after patientdraping. Only on the first surgery of the day, a sample series was performed. Sur-geons involved in the preliminary study did not combine preliminary samplesand surgical sampling on the same day. Time of surgery was recorded in intervalsof 30 min.

Statistical analysis

The obtained values of CFU from PHA, AHA, AG and AS were expressed as log10

values. For calculation purposes, values of 0 (log10 0 = �1) were set to 1(log10 1 = 0). For each sample, a reduction factor (RF) was obtained from the differ-ence of log10 pre-value and post-value. RF1 was the reduction between PHA andAHA (immediate effect) and RF2 was between PHA and AG/AS (sustained effect).The least square mean log10 CFU (LSM log10 CFU) and RF (LSM RF), including stan-dard deviation (SD), of each product was calculated. For the preliminary study, AN-OVA compared the effects of the different antisepsis protocols on the meanlog10 CFU values and RF’s in function of the different steps (PHA, AHA, AG). This var-iance analysis included fixed effects of the surgeon and the left and right hand. Forthe surgical study, the same type of ANOVA comparison was performed for Steril-lium and CHX soap in function of the different steps (PHA, AHA, AS). Fixed effectsof the type of surgery and the presence of glove punctures were additionally in-cluded. Significance was set at P 6 0.05.

Results

Preliminary study

A total of 20 sample series per product were obtained. All sam-ples permitted repeated identification of bacterial growth. Consid-ering LSM log10 CFU PHA, no statistical difference was observedbetween the two surgeons participating in this trial nor betweenthe right and left hand. Significant differences were found betweenimmediate and sustained activities of the different products tested.Sterillium was shown to have significantly lower LSM log10 CFU atAG compared to both other products. At AHA, PVP had significantlyhigher LSM log10 CFU than Sterillium and CHX, with the latter twoproducts having comparable activities. LSM and SD values for thelog10 of CFU between the different hand antisepsis methods canbe found in Table 1 and Fig. 1.

Reduction factors for the Sterillium were significantly greaterthan for the other products. Only RF1 was comparable betweenSterillium and CHX. Table 2 and Fig. 2 show the values and SD ofthe RFs obtained for the different products.

Surgical study

Considering the results of the preliminary study, PVP scrub wasnot included in the surgical trial.

A total of 64 (50 equine, 14 small animals) sample series of Ster-illium and 30 (20 equine, 10 small animal) of CHX soap were ob-tained during the study period. Mean surgery time was 1.5 h. Nosignificant differences were found between surgeons regarding

Table 1Least square means of the log10 CFU between the different steps and between the different soap products used in the preliminary study: CHX, 4% chlorhexidine gluconate soap;PVP, 7.5% povidone iodine soap; Sterillium (45% 2-propanol, 30% 1-propanol, 0.2% mecetronium ethylsulfate). n = 20 for each product.

Step Product

Chlorhexidine gluconate Povidone iodine Sterillium

LSM log10 CFU SD LSM log10 CFU SD LSM log10 CFU SD

PHA 2.262a 0.059 2.223a 0.072 2.219a 0.053AHA 0.158a,⁄ 0.071 1.111b,⁄ 0.175 0.015a,⁄ 0.015AG 0.670a,⁄,� 0.172 0.970b,⁄ 0.159 0c,⁄,� 0

CFU, colony forming unit; PHA, prior to hand antisepsis; AHA, after hand antisepsis; AG, after 3 h of sterile gloving; LSM, least square means; SD, standard deviation.Products (rows): values with a different superscript letter are significantly different. Sampling times (columns): � significantly different from PHA; � significantly differentfrom AHA; P 6 0.05.

Fig. 1. Least square means of the log10 CFU between the different steps andbetween the different products, Hibiscrub (4% chlorhexidine gluconate), Vetclean(7.5% povidone iodine), and Sterillium used in the preliminary study. CFU, colonyforming unit; PHA, prior to hand antisepsis; AHA, after hand antisepsis; AG, after3 h of sterile gloving. LSM, least square means.

Table 2Least square mean reduction factors (LSM RF) for the different products tested in thepreliminary study.

Product

Chlorhexidine gluconate Povidone iodine Sterillium

LSM RF SD LSM RF SD LSM RF SD

RF1 2.104a 0.083 1.116b 0.177 2.204a 0.051RF2 1.592a,⁄ 0.178 1.256b 0.185 2.219c 0.015

RF1, reduction factor between prior to hand antisepsis and after hand antisepsis(immediate effect); RF2, reduction factor 3 h after wearing sterile gloves (sustainedeffect). Products (rows): values with a different superscript letter are significantlydifferent. Reduction factor (column): � significantly different from RF1; P 6 0.05.

Fig. 2. Least square mean reduction factors for the different products Hibiscrub,Vetclean and Sterillium tested in the preliminary study. RF1, reduction factorbetween prior to hand antisepsis and after hand antisepsis (immediate effect); RF2,reduction factor 3 h after wearing sterile gloves (sustained effect). LSM, least squaremeans.

Table 3Least square means of the log10 CFU (LSM log10 CFU) between the different steps forSterillium (n = 61) and CHX (n = 28) in the surgical study.

Step Sterillium Chlorhexidine gluconate

LSM log10 CFU SD LSM log10 CFU SD

PHA 1.876a 0.21 2.123a 0.129AHA 0.048a,⁄ 0.029 0.039a,⁄ 0.011AS 0.018a,⁄ 0.012 0.263b,⁄,� 0.130

CFU, colony forming units; PHA, prior to hand antisepsis; AHA, after hand anti-sepsis; AS, after surgery (mean surgery time 1.5 h); LSM, least square means; SD,standard deviation. Products (rows): values with a different superscript letter aresignificantly different. Sampling times (columns): � significantly different from PHA,� significantly different from AHA; P 6 0.05.

374 D.R. Verwilghen et al. / The Veterinary Journal 190 (2011) 372–377

LSM log10 CFU after hand antisepsis, neither between RF from sam-ples taken at the small animal vs. the equine theatre. Nevertheless,the mean CFU level of the PHA samples from small animal(79.42 ± 63.83) were lower than for equine surgeons (129.2 ±174.14), although the differences were not statistically significant.

Four AS Sterillium samples were excluded from statistical anal-ysis because surgeons contaminated their hands by touching ob-jects or themselves while removing gloves and gowns prior tosampling. One AS sample was excluded from statistical analysis be-cause of the presence of an infected wound at the nail corner of one

of the surgeons creating an extreme growth of Staphylococcus aur-eus on all fingertips prints on the agar gel. Swabbing and culturerevealed the same bacteria to be present in the wound as theone cultured on the AS sample. PHA samples were significantly dif-ferent from AHA and AS samples for both products. No differencewas observed between AHA and AS samples for Sterillium. Sterilli-um AS was significantly different from chlorhexidine gluconate AS.

The RF2 of Sterillium was significantly higher from RF2 of CHX.LSM log10 CFU and RF for Sterillium and CHX used in the surgicalset up can be found in Tables 3 and 4 and Figs. 3 and 4.

Table 4Least square means reduction factors (LSM RF) for Sterillium (n = 61) and CHX (n = 28)obtained in the surgical study.

Sterillium Chlorhexidine gluconate

LSM RF SD LSM RF SD

RF1 2.279a 0.074 2.007a 0.162RF2 2.343a 0.029 1.989b 0.019

SD, standard deviation. Products (rows): values with a different superscript letterare significantly different. Reduction factors (column) � significantly different fromRF1; P 6 0.05.

Fig. 3. Least square means of the log10 CFU between the different steps forSterillium and CHX in the surgical study. CFU, colony forming units; PHA, prior tohand antisepsis; AHA, after hand antisepsis; AS, after surgery (mean surgery time1.5 h); LSM, least square means.

Fig. 4. Least square mean reduction factors (LSM RF) for Sterillium and CHX in thesurgical study.

D.R. Verwilghen et al. / The Veterinary Journal 190 (2011) 372–377 375

Glove puncture

No punctures were found in gloves used in the preliminarystudy (n = 60). Of the 64 gloves used in the surgical study, punc-tures were found in three gloves (4.7%). Two punctures concernedthe non-dominant hand (one index finger and one middle finger)and one glove was punctured on the thumb of the dominant hand.

No statistical relation was found between the presence of glovepuncture and the number of CFU’s present on the hand at AS.

Discussion

This study confirmed that Sterillium was at least as effective inreducing bacterial counts on hands prior to veterinary surgery asCHX and PVP. The greater efficacy of an AHS over traditionally usedmedicated soaps agreed with the literature (Parienti et al., 2002;Kampf and Ostermeyer, 2005; Loffler and Kampf, 2008; Tanneret al., 2008) and, as shown by Parienti et al. (2002), provided bettertolerance and compliance to the surgical hygiene protocol. Despitethis, medicated soaps are still commonly used by veterinary sur-geons and have far more disadvantages than commonly accepted(Kampf, 2008).

The preliminary study revealed that PVP soap was significantlyless active than Sterillium and CHX, while Sterillium and CHX hadcomparable activity. Similarly, Marchetti et al. (2003) showed thatboth Sterillium and CHX met the prEN12791 requirements but PVPdid not. However, the sustained effect of Sterillium after 3 h ismarkedly better than CHX (Pietsch, 2001; Kampf et al., 2002;Marchetti et al., 2003), despite an expectation that CHX has a goodresidual effect (Pereira et al., 1997), which does not appear to becorrect (Reichel et al., 2008).

The problem with interpreting CHX residual activity is thatinsufficient neutralisation will influence the outcomes (Sheikh,1981). However, to be comparable with similar studies (Kampf,2009), a neutralising agent was not added in the current studyand bacteriostatic concentrations of CHX in the Petri plates proba-bly extended beyond the actual exposure time. The low number ofsurviving organisms suggested a high activity of CHX which couldnot be explained by the efficacy during the exposure time (i.e.,hand washing) and was more likely related to the tendency ofnon-volatile agents, such as CHX, to remain on the plate (Kampfet al., 2005; Reichel et al., 2008).

Our study confirmed an earlier report (Marchetti et al., 2003)that PVP is unlikely to be useful in vivo, despite good in vitro activ-ity. There was also no obvious un-sustained activity of PVP (Rotteret al., 1980). Furthermore, staining and irritation caused by the useof PVP may limit its clinical use. However, PVP has been reportedto have strong activity against methicillin-resistant Staphylococcusaureus (MRSA) (Haley et al., 1985; McLure and Gordon, 1992) andother resistant bacteria (Durani and Leaper, 2008), so may still beuseful as a general antiseptic solution in clinical practice.

As the preliminary testing revealed PVP to be inefficient in vitro,only Sterillium and CHX were tested during the surgical study. Thein-use test demonstrated a significantly greater reduction in theCFU for Sterillium, compared to CHX, by the completion of smallanimal or equine surgery – findings that agreed with a similarstudy during cardiothoracic surgery (Carro et al., 2007). Moreover,Sterillium solution had a significantly better immediate and sus-tained effect than PVP scrub in the ambulatory surgery theatre ofa tertiary care university hospital (Kac et al., 2009).

The in vivo method used in this study to obtain a CFU count wassimilar to previous reported work (Carro et al., 2007; Kac et al.,2009; Rotter et al., 2009). The method tests the presence of micro-organisms on the fingertips, as different surveys have shown thebacterial burden to be the highest at this location and to reflectgeneral hand contamination (Kampf et al., 2006). Furthermore,we showed that bacteria will rapidly spread to other fingers onceany finger becomes contaminated (as was illustrated by the woundon a finger of one of our surgeons). Moreover, transient and infec-tious flora generally is acquired by touching other people, animalsor contaminated environmental surfaces. Most importantly, surgi-cal glove perforation most often occurs at the fingertips (Tanner,

376 D.R. Verwilghen et al. / The Veterinary Journal 190 (2011) 372–377

2008). Sampling fingertips can therefore be considered an appro-priate method to investigate contamination, particularly whenother valid methods, such a measuring contamination in ‘glovejuice’ (Nishimura, 2006) or by using the in vitro European EN12791 test methodology (2005), are not practical for in vivo trialsinvolving surgery.

The impact of surgical glove perforation on the number of CFUswas not established in the present study due to the low prevalenceof perforated gloves. Collection of gloves should therefore continueover a longer period of time to confirm any link between perfora-tion and CFU development and the theory that glove puncture oc-curs most frequently on the index finger of the non-leading hand(Dodds et al., 1988; Eklund et al., 2002; Yinusa et al., 2004).

Ideally, the efficacy of hand antisepsis protocols should be per-formed by trials attempting to measure the impact of hand anti-sepsis on SSI rates and not on the number of CFU’s found onhands (Tanner et al., 2008). However, the only study performedto date reported no difference in SSI rates between surgical teamsusing a 5 min duration rubbing or scrubbing method when com-paring AHR, CHX and PVP (Parienti et al., 2002). More studies aretherefore needed that have SSI as the primary endpoint.

A further consideration in the choice of hand rubbing antisepsisprotocols is that AHR has been reported as having better toleranceand compliance amongst surgeons after 4 and 14 months of use(Parienti et al., 2002), which was confirmed in our study.Alcohol-based hand rubs had never been used in our hospital butfollowing this study their use has now been implemented and ac-cepted amongst surgeons without any complaints about dermaltolerance.

Finally, it should be noted that not every alcoholic rub solutionsold over the counter is appropriate for use in surgical hand prep-aration as they may contain different alcohol concentrations andshould have passed European or American regulatory agenciestesting in that regard.

Conclusions

The alcoholic-based rub used in this study performed betterthan disinfecting soaps and was suitable for veterinary surgicalhand disinfection. Alcoholic-based rub’s are cheaper, can beapplied more rapidly, have greater skin tolerance and cause lessenvironmental impact (Cimiotti et al., 2004).

Conflict of Interest statement

None of the authors of this paper have a financial or personalrelationship with other people or organizations that could inappro-priately influence or bias the content of the paper.

Acknowledgements

The authors would like to particularly thank Jean-Noel Duprezfor his assistance in the preparation of the agar plates and technicalaspects of the study. We thank Georg von Schwartzenberg, MireilleWeber and Rachel Paquai for their assistance in this study andSusan Atkins, Birgitt Rimell and Maria Silabon for their linguisticcorrections to the manuscript.

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