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Journal Club

September 2010

Surgical hand antisepsis to reduce surgical site infection

• Authors: Tanner J, Swarbrook S, Stuart J.
  
• Institution:De Montfort University and University Hospitals Leicester, Leicester, UK
  
• Journal: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004288.

Introduction

• Cochrane Review 2008
• Objectives
  
• To determine the effects of surgical hand antisepsis on
  • Surgical site infections (SSIs)
  • Number of colony forming units (CFUs) of bacteria on the hands of the surgical team

Methodology

• Inclusion criteria
  
  • Published/unpublished RCTs
• Type of intervention
  
  • Surgical hand antisepsis
    
  • Aqueous scrub solutions
    
  • Alcohol rubs
    
  • Alcohol rubs containing additional active ingredients
    
  • Surgical hand antisepsis of different durations
    
  • Surgical hand antisepsis with different equipment
• Outcome measures
  
  • Primary
    
    • SSIs
      
  • Secondary
    
    • CFUs of bacteria on hands
• Electronic searches
  
  • Cochrane Wounds Group Specialised Register
    
  • CENTRAL
    
  • Ovid MEDLINE
    
  • Ovid EMBASE
    
  • Ovid CINAHL
    
  • ZETOC database of conference proceedings
• 3 authors independently assessed papers
  
• Data extraction according to standardised form – by two authors independently and cross checked by third
• Assessment of risk of bias
  
  • Adequacy of randomisation
    
  • Adequacy of concealment
    
  • Blinding
    
  • Intention to treat analysis
    
  • Completeness of follow up
    
  • Pre-trial sample size calculations
    
  • Use of clear inclusion/exclusion criteria
• Data synthesis
  
  • Continuous outcomes – CFUs – weighted mean differences and 95% CI
    
  • Dichotomous outcomes – SSIs – RR and 95% CI
    
  • No metaanalyses due to heterogeneity of studies

Results

• 10 studies included
  • 1 only reported on SSIs
  • 9 reporting on CFUs
    • Four trials – relative effects of different types of aqueous scrubs
      
    • Two trials – relative effects of alcohol rubs with additional active ingredients
      
    • Six trials – compared aqueous scrub with alcohol rub with additional active ingredients
      
    • Four trials – duration of scrub
      
    • No trials – antisepsis vs no antisepsis
      
    • No trials – comparing alcohol only rubs
      
    • No trials – brushes, sponges etc
• Study details
  
  • 2 Australia, 2 US, 2 Germany, France, Spain, Japan, UK
    
  • 5 studies - participants took part in surgical procedures
    
  • Range of specialties
    
  • 5 trials only provided detailed description of the antisepsis technique
    
• Outcome measures
  
  • SSIs (Parienti JAMA 2002)
    
    • 30 day follow up
      
    • SSI according to CDC guidelines
      
    • Confirmed by surgeon
• CFUs (9 studies)
  
  • 2 finger press method
    
  • 7 glove juice method (FDA considered 'gold standard')
    
• Aqueous scrubs vs alcohol rubs containing additional active ingredients
  
• 5 studies
  
• No meta analysis possible
  
• 4 used CFUs as primary outcome measure
  
  • 2 rub significantly better
    
  • 1 rub significantly worse
    
    • 4 participants only
      
    • Finger press method
      
  • 1 equivocal
    
    • Insufficient raw data for independent analysis
      
• Parienti JAMA 2002
  
  • Multi center in France 2000-01
    
  • French Government funding
    
  • Randomised equivalence trial – pre-trial power calculation performed
    
  • 4387 consecutive patients undergoing clean or clean-contaminated surgery
    
  • Intervention
    
    • Hand rub with 75% aqueous alcoholic solution containing pro- panol-1, propanol-2, and mecetronium etilsulfate
      
    • Scrub with antiseptic preparation containing 4% povidone iodine or 4% chlorhexidine gluconate
      
  • Outcome measure
    
    • SSIs in first 30 days
      
    • CDC definition – confirmed by surgeon
      
    • Secondary
      
      • Compliance/tolerance
        
    • Method
      
      • Cluster, crossover
        
      • Intervention changed at each service each month for 15 months
        
  • Results
    
    • Scrub
      
      • 53/2135 SSIs (2.48%)
        
    • Rub
      
      • 55/2252 (2.44%)
        
    • Significantly better compliance and tolerance in rub group
• Chlorhexidine vs povidone iodine aqueous scrub
  
  • 4 studies
    
  • Pooling not possible
    
  • Chlorhexidine significantly fewer CFUs
• Comparison of different alcohol rubs containing additional active ingredients
  
  • 2 trials
    
  • 1 compared chlorhexidine plus different alcohols
    
  • 1 compared alcohol plus chlorhexidine or zinc pyrithione
    
  • No difference between alcohol rubs
• Duration of antisepsis
  
  • 4 trials
    
    • 2 min vs 3 min scrub
      
    • 5 min rub vs 3 min rub
      
    • 5 min/3min scrubs vs 3 min/30 sec scrub with chlorhexidine
      
    • 5 min/3min scrubs vs 3 min/30 sec scrub with povidone iodine
      
    • 5 min/3.5 min scrubs vs 3 min/2.5 min scrubs using chlorhexidine
  • 3 minute rub is better than 5 minute rub
    
  • No difference in scrub times over 30 seconds
• No papers
  
  • Comparing antisepsis with no antisepsis
    
  • Comparing alcohol only rubs
    
  • Comparing alcohol only rubs with rubs containing additional active ingredients
    
  • Brushes, sponges et

Discussion

• Hands a potential source for transfer of bacteria
  
  • Glove permeability
    
  • Glove tears/punctures
    
• Surgical site infections
  
  • Common
    
    • 10% UK, 38% US
      
  • Costly
    
  • Potentially devastating
    
• Antiseptic agents need to be
  
  • Fast
    
  • Effective
    
  • Persistent
    
  • Cumulative
    
  • Tolerable
    
  • Broad spectrum of activity
    
• Potential benefits of alcohol based rubs
  
  • Compliance
    
  • Better tolerated
    
  • Less time consuming
    
  • Less expensive
    
    • 203 vs 25 euros per week – Girard 1996
      
  • Water saving
    
  • At least equivalence in level of antisepsis

Review Findings

• Chlorhexidine scrub is superior to povidone iodine scrub
• Concentration of alcohol in hand rubs is more important than the type of alcohol
• Safe to use alcohol rub with additional active ingredients as an alternative to the initial and subsequent scrubs

Pros of Study

• well conducted

Cons of Study

• Limitations
  
  • Most papers use surrogate marker
    
    • Colony forming units
      
  • Reporting of SSIs is difficult
    
  • Heterogeneity of studies
    
  • Large numbers required
    
    • Particularly for SSIs
      
    • Dichotomous vs continuous variable