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

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

4. 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)

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

6. 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.

7. Method of scrubbing

8. Aqueous Scrubbing Group

9. Opinions: Anti-microbial effect

10. Opinions: Dermatitis

11. Alcohol Rub Group

12. Opinions: Anti-microbial effect

13. Opinions: Dermatitis

14. 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

15. 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.

16. 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.

17. Antimicrobial efficacy
(Pittet & Boyce, 2001)

18. 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)

19. 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

20. 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.

21. 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.

22. References
Pittet D, Boyce J. (2001) Hand hygiene and patient care: pursuing the Semmelweis legacy. The Lancet Infectious Diseases 1. p
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
Tanner J, Swarbrook S, Stuart J. (2008) Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews. Rev
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