[Matthias.Maiwald@KKH.COM.SG Subject: Re: Waterless Surgical Scrubs Comments: cc: awidmer@uhbs.ch In-Reply-To:]

Hi Phil,

Thank you. Alcohol-based surgical hand antisepsis is definitely suitable
also for the first scrub of the day, not just the subsequent ones. The main
prerequisite (also stated in the article that you cite) is that the hands
are clean. In the setting of my surgical internship in the 1908s that I
described, it was achieved by everyone doing a soap-based hand- and
arm-wash anyway, followed by drying with a sterile towel (alcohol would not
act if hands/arms were still wet) before applying alcohol. That got
everyone to have the ‘baseline’ of clean hands before applying alcohol.
According to WHO 2009 and the article you cite, that is apparently no
longer the state of the art, although having clean hands is definitely
stipulated.

As stated, there are no clinical trials with infection rates as the outcome
that show superiority of one regimen over another. In fact, surgical
scrubbing itself has never been proven in clinical trials. Nevertheless,
there is a strong microbiological and pathophysiological rationale
supporting it, as well as anecdotal reports of catastrophic infections when
there were lapses. Given that microbiological evidence is then the next
best source (and arguably a very good one, because it relates directly to
the pathogenetic principle, which is microorganisms on hands), then the
evidence base for scrubbing with aqueous agents is definitely much weaker
— by a huge margin — than for alcohol-based scrubbing, and that includes
the first scrub of the day.

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 1389
Fax +65 6394 1387

“RUSSO, Philip”
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Re: Waterless Surgical Scrubs

10/08/2010 11:26
AM

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AICA Infexion
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Nice summary Matthias. We are not aware of any evidence that would
suggest the first wash of the day in OR be done with anything but soap
and water. Certainly subsequent to that, but not the first.

Surgical hand preparation: State of the art.
Widmer AF, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce J, Pittet D.
J Hosp Infect. 2010 Feb;74(2):112-22. Epub 2009 Aug 28. Review.

Regards
Phil Russo, M.Clin.Epid
Hand Hygiene Australia
National Project Manager
P: +61 3 9496 3587 | M: +61 411 659 486 |F: +61 3 9496 6677 |E:
philip.russo@austin.org.au
http://www.hha.org.au/
Hand Hygiene Australia, c/- Austin Health Infectious Diseases Dept. PO
5555 Heidelberg, VIC, Australia 3084

—–Original Message—–
Behalf Of Matthias.Maiwald@KKH.COM.SG

Dear Cath, dear Group,

“Waterless surgical scrubs” or alcohol-based surgical hand/arm
antisepsis (as it is better called) has been the standard of care in
Europe (especially Germany, Austria, Switzerland) for about 30 years or
longer.
(In fact, one now retired author describes in a book chapter [Groeschel
& Pruett, Surgical Antisepsis, in Block 1991] that it has already been
in use in the 1950s). How it is done (at least in the 80s when did my
surgical
internship) is to do a soap-based handwash (plus arms) and to scrub with
a brush only under fingernails (not on other skin) for the first scrub
of the day, followed by drying of hands/arms with a sterile towel (not
paper) and followed by rubbing the alcohol-based hand disinfectant onto
hands and arms and keeping them ‘wet’ with alcohol for 5 minutes. Then
letting the alcohol dry (as for a normal alcohol hand rub) before
gowning and gloving. One of the speakers at the recent Infection Control
Course in Port Douglas, Andreas Widmer from Switzerland, has been
presenting on this topic at ICAAC meetings, and it appears that the
tendency goes towards shorter scrubbing times now (than in the 80s), and
about 3 min is consideres satisfactory.

There are two main advantages: (a) it is more gentle to skin, consistent
with alcohol-based hand antiseptics having emollients, and (b) it
achieves far greater microbial reduction. While water-based surgical
scrubbing achieves a microbial reduction typically by about 1-2 log
(factor 10-100), alcohol-based surgical hand antisepsis achieves about
3-4 log reduction (factor 1000-10000, that is a factor 10-100 better
than water-based scrubbing. When agents for persistence are added, then
there is no or only minimal regrowth of microorganisms under the
surgical gloves for the duration of the operation. In fact, the lack of
significant regrowth is assessed as part of the European standard EN
12791 for surgical hand antiseptics. Note that no aqueous surgical scrub
stands a chance of passing this stringent testing standard.

One should mention that there are no clinical trials with surgical
infection rates as the outcome that show a difference in infection rates
between water-based and alcohol-based scrubs, however, the much lower
residual microorganisms provide a strong microbiological and
pathophysiological rationale that at least there is a greater safety
margin in case of accidental glove leaks or rupture (which is what
surgical acrubbing is designed for).

And yes, there is a section on surgical scrubbing, including alcohol
formulations, in the new 2009 WHO hand hygiene guideline.

I would personally strongly advocate NOT to use gels for that purpose,
because most gels have distinctly less antimicrobial activity than
liquids, because surface coverage is more difficult to achieve with the
more viscous gels, and because gels often leave a sticky residue, which
will be uncomfortable under the surgical gloves. There are a number of
European companies that have alcohol-based surgical hand antiseptics in
their product range; they are specially formulated for that purpose and
pass the stringent EN 12791. Not to make undue advertisements, but among
the European companies with such products in their range and an
established distribution network in Australia is B. Braun. (Of course,
there are several other possibilities with equally good products).

And yes, TGA should look at approving some of these, in my opinion.

I do have some literature about this, which I am certainly offering to
share.

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Department of Pathology and Laboratory Medicine KK Women’s and
Children’s Hospital 100 Bukit Timah Road Singapore 229899 Tel. +65 6394
1389 Fax +65 6394 1387

Cath Murphy

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Waterless Surgical Scrubs

09/08/2010 06:01

PM

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AICA Infexion

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Dear AICA, ACSQHC and ACORN Colleagues

I have been asked about the suitability of using “waterless surgical
scrubs” as an alternative to the first ‘soap and water’ wash of the day
in the operating theatre or surgical procedural unit. Does anybody know
if this is common? Acceptable? Widespread and based on credible evidence
or policy?

Any commentary welcomed. Thanks.

Cath

Assoc. Prof Cathryn Murphy RN PhD CIC
CNC Infection Control
Gold Coast Health Service District
Robina Hospital
Gold Coast

http://www.icp.au.com

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