New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective
Recommendation 11: surgical hand preparation
Surgical hand preparation is vitally important to maintain the least possible contamination of the surgical field, especially in the case of sterile glove puncture during the procedure. Appropriate surgical hand preparation is recommended in the WHO guidelines on hand hygiene in health care issued in 2009114 and in all other existing national and international guidelines for the prevention of SSIs. We did a systematic review to compare the effect of different techniques (ie, hand rubbing vshand scrubbing), products (ie, different formulations of ABHRs vs plain soap vs medicated soap), and application times for the same product.
We only found six studies (three RCTs115, 116, 117 and three observational studies118, 119, 120) with SSI as the primary outcome that compared hand rubbing with hand scrubbing using different products. Five studies compared ABHR with hand scrubbing with an antimicrobial soap containing either 4% povidone-iodine or 4% chlorhexidine gluconate and showed no significant difference in SSI incidence.115, 117, 118, 119, 120 Additionally, no significant difference was seen in a cluster randomised cross-over trial comparing ABHR to hand scrubbing with plain soap.116 It was not possible to do any meta-analysis of these data because the products used for hand rubbing or scrubbing were different. The overall evidence (rated as moderate quality) showed no difference between hand rubbing and hand scrubbing in reducing SSI incidence. Evidence from additional studies using the bacterial load on participants’ hands as the outcome showed that some ABHR formulations are more effective to reduce colony-forming units than scrubbing with water and antiseptic or plain soap. However, the relevance of this outcome to the risk of SSI is uncertain. Because of the use of different protocols, it was not possible to identify optimal application times for the two techniques. When selecting an ABHR, health-care facilities should procure products with proven efficacy according to international standards and position no-touch or elbow-operated dispensers in surgical scrub rooms. In LMICs in which ABHR availability might be low, WHO strongly encourages facilities to undertake the local production of an alcohol-based formulation, which has been shown to be a feasible and low-cost solution.121, 122 Alternatively, antimicrobial soap, clean running water, and disposable or clean towels for each health-care worker should be available in the scrub room.