Pre-operative surgical scrubs: review of evidence and survey of current practice Dr. Suraindra Mark Rajadurai General Surgical Trainee Western Hospital, Melbourne VIC

Disclosures No conflicts of interest No funding or scholarships were received for this project

Pre-operative surgical scrubbing Oliver Wendell Holmes Snr. “The contagiousness of puerperal fever” – New England Quarterly Journal of Medicine and Surgery (1843) Ignaz Semmelweis Etiology, Concept and Prophylaxis of Childbed Fever (1847) Louis Pasteur “De l'extension de la théorie des germes à l’étiologie de quelques maladies communes” (1867) Lord Joseph Lister “On a new method of treating compound fracture, abscess etc.: with observations on the conditions of suppuration” – Lancet (1867)

What do surgeons in Australia do? Online survey distributed to surgeons and registrars via email Small number of questions Answerable in less than 5 minutes

148 Respondents 71% of respondents were consultants Specialty General Surgery 64 Orthopaedics 52 Paediatric Surgery 7 Cardiothoracics 5 Plastics and Reconstructive Urology 4 Vascular ENT 3 Neurosurgery 2 Ophthalmology 71% of respondents were consultants 71% of respondents were consultants.

Method of scrubbing

Aqueous Scrubbing Group

Opinions: Anti-microbial effect

Opinions: Dermatitis

Alcohol Rub Group

Opinions: Anti-microbial effect

Opinions: Dermatitis

Survey Conclusions: Most respondents used an aqueous traditional scrub The most common stated motivations for this were: Habit (26%) Allergic reactions to Iodine (31%) Most efficacious at killing microbes (21%) However 52% of those using a traditional scrub felt that an alcohol based rub would be more efficacious at killing microbes

Survey conclusions (cont.) Of the alcohol rub group the most common motivations were: Most efficacious at killing microbes (53%) Ease of use (15%) Most respondents felt that iodine was the most damaging to skin.

Current Evidence Guidelines NHMRC (2010): any TGA approved antiseptic surgical scrub, preferably alcohol based. WHO (2009): alcohol containing compounds are more efficacious and should ideally be used in preference to antiseptic wash. NICE (2008): either an alcohol rub or a surgical antiseptic wash. CDC (2007): alcohol containing products are more efficacious and should be used preferentially.

Antimicrobial efficacy (Pittet & Boyce, 2001)

Costs Increased costs associated with scrubbing when water and brushes factored in These costs can rise significantly if water filters are used (Tavolacci, 2005) Tavolacci – 0.30 euro cents for rub, approx. 1 euro for wash (same for chlorhex and iodine)

Pitfalls Meta-analysis is difficult (Tanner et al. 2008): Studies often use different reference products Different standards for testing efficacy of products/methods Require very large numbers to test for surgical site infection (Parienti, 2002) Parienti 2002 – 4387 patients, equivalence cluster randomised cross-over trial, 2.5% scrub group, 2.4% rub group

Conclusions There is evidence favoring alcohol-based rubs over traditional surgical scrubs in terms of: Antimicrobial efficacy Cost Ease of use Current practice in the survey group does not reflect this.

References Australia. National Health and Medical Research Council. (2010). Australian Guidelines for the Prevention and Control of Infections in Healthcare. Canberra, Australia. WHO. World Health Organization. (2009). WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland. Great Britain. National Institutes for Health and Clinical Excellence. (2008). Surgical Site Infection – Prevention and treatment of surgical site infection. London, UK. United States of America. Centers for Disease Control and Prevention. (2007). Guidelines for Hand Hygiene in Health-Care Settings. Atlanta, GA.

References Pittet D, Boyce J. (2001) Hand hygiene and patient care: pursuing the Semmelweis legacy. The Lancet Infectious Diseases 1. p. 9-20. Tavolacci M, Pitrou I, Merle V et al. (2006) Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs. The Journal of Hospital Infection. 63(1). p. 55-59 Tanner J, Swarbrook S, Stuart J. (2008) Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews. Rev 1 2008. Parienti J, Thibon P, Heller R et al. (2002) Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA. 288(6) p. 722-728