Dear Editor, Surgical hand antisepsis (‘surgical scrubbing’) has been the topic of a recent article in this journal, as well as of several recent posts on the Australasian College for Infection Prevention and Control (ACIPC) email list ‘Infexion Connexion’. The article and the list discussion focused on the use of alcohol-based hand rubs for this purpose, which is a relatively new development in the Australian setting as opposed to ‘traditional’ surgical hand antisepsis with water and detergent-based antiseptics such as chlorhexidine or povidone–iodine antiseptic soaps. I would like to add another aspect to the discussion; this is the issue of correct technique, including appropriate hand and arm surface coverage, when using alcohols for surgical hand antisepsis. Alcohols for surgical hand antisepsis have three main advantages. First, they create far greater microbial reduction on hands and arms than is possible with any detergent-based antiseptics. In particular, products that meet the stringent European standard EN 12791, whereby an agent is compared to the reference of 60% (v/v) n-propanol, typically produce logarithmic (log) reductions between 2 and 3, with sustained values at 3 h under surgical gloves of around 2, where the baseline is normal resident hand flora before antisepsis. Second, alcohols with added emollients are generally better tolerated on hands and skin than detergents, particularly when frequent antisepsis is necessary. Third, the time requirements for alcohol-based antisepsis are shorter; most products require only 3min (this is also the time specified in standard EN 12791), and there are now newer products that achieve equivalent microbial reduction in only 1.5min of application. However, although microbiological principles and biological plausibility strongly support greater rather than lesser microbial reduction, so far there are no clinical trials showing that this translates into fewer surgical site infections. Alcohol-based as well as detergent-based surgical hand antisepsis has been incorporated into recent guidelines by the USCenters for Disease Control and Prevention (CDC), the Association of periOperative Registered Nurses (AORN) and the World Health Organization (WHO). There are two types of settings with regard to surgical hand antisepsis: (1) settings where alcohol-based agents have been predominantly or exclusively used for many decades, such as countries in central Europe, and (2) settings where detergentbased antisepsis has been the predominant method, such as Australia or the USA. In settings where something is frequently practised, in particular in the operating room environment, a practice becomes highly ritualised and is taught to new personnel and supervised (often fiercely) by experienced senior nurses or surgeons. Such practices then become engrained and assume elements that are not easily conveyed by textbooks or the scientific literature. In my own surgical internship in Germany, surgical hand antisepsis (termed ‘surgical hand disinfection’) was practised as follows. For the first procedure of the day, we did a hand and forearm wash with soap and water, including brushing or scraping only under the fingernails. Then, hands and forearms were dried using a sterile standard towel (remaining water on hands would compromise the efficacy of alcohol). This was followed by a 5-min alcohol hand rub (with a liquid product) whereby the alcohol was repeatedly and liberally dispensed from a wall-mounted, elbow-driven dispenser and rubbed onto hands and forearms, such that they were literally kept wet with alcohol and all surfaces covered for the entire period. The alcohol was then left to dry by evaporation. Current recommendations no longer require washing hands before using alcohol, and the application times have become shorter. The WHO guidelines state that prior hand washing is only necessary when hands are visibly dirty and that for most products, 3min of application are sufficient. The guidelines recommend approximately 3 5mL (total 15mL) for the procedure, but they emphasise that it is important to keep hands and arms wet during the entire procedure. In any case, this technique is fundamentally different from regular ward-based hand antisepsis according