Surgical hand preparation without rinsing: influence of antiseptic agent on bacteriological contamination

Abstract

Hospital infections represent a global public health problem and are a risk to users of hospital services. Postoperative infections, currently referred to as surgical site infections (SSI), account for a significant proportion of all of these hospital infections.1 Among the practices for the prevention of SSI, degermation of the hands and forearms of the surgical team, as a preoperative preparation, had its origin when Ignaz Semmelweis, in 1847, advocated the use of germicide for washing hands before examining the parturient.2,3 The effect of skin antisepsis on reducing surgical site infection has been historically demonstrated by Joseph Lister (1827-1912). At that time, surgical gloves were not yet available, which made proper antisepsis of the patient’s skin and of the hands of the surgeon even more important.4 The hands act as a reservoir of microorganisms, considered the main route of transmission of pathologies, presenting the highest index of hospital infection. Even with the use of gloves, micro perforations may occur due to their use, in addition to contamination of the hands during their withdrawal.5 Human skin is colonized by bacteria, whose density varies according to the sites. The species found in the hands are classified into two groups: resident microbiome and transient microbiome.6 The bacteria of the transient microbiome, despite having greater pathogenicity, appear to be removed by hand hygiene, as they are more superficially and poorly adhered to the skin.7 The hand hygiene activity has been associated with a significant reduction of hospital infections. Evidence from experimental and non-experimental studies is fairly consistent with the hypothesis that handwashing is a causal association with reduced risk of infection.6−9 Care with the surgical degermation of the hands and forearms is justified by the perforation rate of the gloves at the end of the surgery of 18%, and in more than 35% of the cases these perforations are not perceived by the surgeons, besides the fact that some gloves are permeable to bactéria.10 The purpose of pre-surgical antisepsis is to reduce the resident and transient microbial load of the hands, thus reducing the introduction of microorganisms into the surgical site1. It is fundamental for the practice of hygiene, especially when referring to a health professional, who, in order to perform any type of surgical procedure, should use antiseptic solutions because they promote a greater reduction of microorganisms.6 Not necessarily this technique requires soap and water to be effective. Clinical trials have demonstrated the effectiveness of techniques without rinsing, in which alcohol-based solutions are used for pre-surgical hygiene.6,9,11,12 To help countries and health facilities adopt alcohol-based products as a gold standard for hand hygiene, the World Health Organization (WHO) has developed formulations for local preparation as an alternative when appropriate commercial products are not available or are very expensive. These formulations have presented excellent tolerability, good acceptance, low cost and high importance for the clinical effect.11 The WHO proposes two possibilities of manipulation, being one based on ethyl alcohol and another one based on isopropyl alcohol. Considering that these active principles provide different potentials for reducing microbial load,13 this study aimed to verify the efficacy and influence of antiseptic agents on the degree of bacteriological contamination of the hands, after pre-surgical hygiene without rinsing, using the products recommended by WHO.