13.1. Evidence for surgical hand preparation
Historically, Joseph Lister (1827-1912) demonstrated the effect of disinfection on the reduction of surgical site infections (SSIs).506 At that time, surgical gloves were not yet available, thereby making appropriate disinfection of the surgical site of the patient and hand antisepsis by the surgeon even more imperative.507 During the 19th century, surgical hand preparation consisted of washing the hands with antimicrobial soap and warm water, frequently with the use of a brush.508 In 1894, three steps were suggested: 1) wash hands with hot water, medicated soap, and a brush for 5 minutes; 2) apply 90% ethanol for 3-5 minutes with a brush; and 3) rinse the hands with an “aseptic liquid”.508 In 1939, Price suggested a 7-minute handwash with soap, water, and a brush, followed by 70% ethanol for 3 minutes after drying the hands with a towel.63 In the second half of the 20th century, the recommended time for surgical hand preparation decreased from >10 minutes to 5 minutes.509-512 Even today, 5-minute protocols are common.197 A comparison of different countries showed almost as many protocols as listed countries.513
The introduction of sterile gloves does not render surgical hand preparation unnecessary. Sterile gloves contribute to preventing surgical site contamination514 and reduce the risk of bloodborne pathogen transmission from patients to the surgical team.515 However, 18% (range: 5-82%) of gloves have tiny punctures after surgery, and more than 80% of cases go unnoticed by the surgeon. After two hours of surgery, 35% of all gloves demonstrate puncture, thus allowing water (hence also body fluids) to penetrate the gloves without using pressure516 (see Part I, Section 23.1). A recent trial demonstrated that punctured gloves double the risk of SSIs.517 Double gloving decreases the risk of puncture during surgery, but punctures are still observed in 4% of cases after the procedure.518,519 In addition, even unused gloves do not fully prevent bacterial contamination of hands.520 Several reported outbreaks have been traced to contaminated hands from the surgical team despite wearing sterile gloves.71,154,162,521-523
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Koiwai and colleagues detected the same strain of coagulase-negative staphylococci (CoNS) from the bare fingers of a cardiac surgeon and from a patient with postoperative endocarditis with a matching strain.522 A similar, more recent outbreak with CoNS and endocarditis was observed by Boyce and colleagues, strain identity being confirmed by molecular methods.162 A cardiac surgeon with onychomycosis became the source of an outbreak of SSIs due to P. aeruginosa, possibly facilitated by not routinely practising double gloving.523 One outbreak of SSIs even occurred when surgeons who normally used an antiseptic surgical scrub preparation switched to a nonantimicrobial product.524
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Despite a large body of indirect evidence for the need of surgical hand antisepsis, its requirement before surgical interventions has never been proven by a randomized, controlled clinical trial.525 Most likely, such a study will never be performed again nor be acceptable to an ethics committee. A randomized clinical trial comparing an alcohol-based handrub versus a chlorhexidine hand scrub failed to demonstrate a reduction of SSIs, despite considerably better in vitro activity of the alcohol-based formulation.197 Therefore, even considerable improvements in antimicrobial activity in surgical hand hygiene formulations are unlikely to lead to significant reductions of SSIs. These infections are the result of multiple risk factors related to the patient, the surgeon, and the health-care environment, and the reduction of only one single risk factor will have a limited influence on the overall outcome.
In addition to protecting the patients, gloves reduce the risk for the HCW to be exposed to bloodborne pathogens. In orthopaedic surgery, double gloving has been a common practice that significantly reduces, but does not eliminate, the risk of cross-transmission after glove punctures during surgery.526
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