Terminology in surgical hand disinfection—a new Tower of Babel in infection control

Abstract

Surgical hand antisepsis is accepted as a key element for preventing surgical-site infections and it is routine in operating theatres worldwide. 1 Boyce J.M. Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. 2002; 51: 1-45 Google Scholar Its rationale is two-fold: first, it is known that perforations are found, on average, in 18.2% of surgical gloves, 2 Kralj N. Beie M. Hofmann F. Surgical gloves—how well do they protect against infections?. Gesundheitswesen. 1999; 61: 398-403 PubMed Google Scholar and even when double-gloving is used, the frequency of perforation is still 4.2%. 2 Kralj N. Beie M. Hofmann F. Surgical gloves—how well do they protect against infections?. Gesundheitswesen. 1999; 61: 398-403 PubMed Google Scholar Second, both transient and resident micro-organisms may enter a sterile body cavity or wound through the leaks in a surgical glove and cause infection. 3 Kampf G. Kramer A. Epidemiological background of hand hygiene and an evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004; 17: 863-893 Crossref PubMed Scopus (518) Google Scholar Many different terms have been used to describe the efficacy of preparations for surgical hand antisepsis. These terms include ‘0-h effect’, ‘3-h effect’, ‘6-h effect’, ‘immediate effect’, ‘long-term effect’, ‘sustained effect’, ‘persistent effect’, ‘residual effect’ and ‘remnant effect’. Although some terms have been defined in norms or recommendations, they lack a consistent scientific justification. A simple question therefore needs to be asked: what is the aim of surgical hand antisepsis? The answer may be helpful in order to define appropriate terms. The aim of a procedure for surgical hand antisepsis is the elimination of transient micro-organisms and the reduction of resident micro-organisms from the hands of the surgical team for the duration of an operation, in order to reduce the risk of surgical-site infection caused by an unnoticed leakage of the surgical glove. A procedure that does not significantly reduce the resident flora at the beginning of an operation or does not keep the microbial release from the hands below baseline until the end of an operation is, therefore, inadequate. In Europe, a reference procedure has been defined that consists of the application of n-propanol (60%, v/v) for a total of 3 min. This procedure has been shown to have an optimum efficacy on resident hand bacteria 4 Rotter M.L. Simpson R.A. Koller W. Surgical hand disinfection with alcohols at various concentrations: parallel experiments using the new proposed European standards methods. Infect Control Hosp Epidemiol. 1998; 19: 778-781 Crossref PubMed Scopus (50) Google Scholar to lower the bacterial release immediately by a log 10 factor of 2.7, and to keep the microbial density 3 h after application below baseline, on average by a factor of 102.2-fold. 5 Kampf G. Ostermeyer C. The 3 minute surgical reference disinfection of prEN 12791: does the applied volume influence the efficacy?. Appl Environ Microbiol. 2004; 70 ([in press]) Crossref PubMed Scopus (26) Google Scholar Recent data suggest that even after 6 h, the microbial density remains, on average, below baseline by a factor of 100.9-101.1 after a 3-min reference disinfection in accordance with prEN 12791 (Rotter ML et al., unpublished data). In terms of surgical hand antisepsis, this type of procedure is, therefore, considered to be adequate for operations of up to 6-h duration. An analysis of 569593 operations revealed that 88.5% lasted for 3 h or less and 99.9% lasted for 6 h or less. 6 Anonymous National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2003, issued August 2003. Am J Infect Control. 2003; 31: 481-498 Abstract Full Text Full Text PDF PubMed Scopus (604) Google Scholar Only a minority of surgical procedures, such as head and neck surgery, usually last longer than 6 h. 6 Anonymous National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2003, issued August 2003. Am J Infect Control. 2003; 31: 481-498 Abstract Full Text Full Text PDF PubMed Scopus (604) Google Scholar This suggests that a 3-h effect compared with the European reference (n-propanol) represents approximately 88.5% of surgical reality.