Surgical Scrub and Skin Disinfection

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Abstract
The role of pre-operative disinfection of the surgeon's hands and the skin of the operative site in the prevention of wound infection remains uncertain. The normal resident skin flora, consisting mainly of coagulase-negative staphylococci and aerobic and anaerobic diphtheroids, is an uncommon cause of infection except in prosthetic operations. Staphylococcus aureus is rarely a resident on normal skin other than the perineum, and is mostly present on the hands as a transient acquired from the nose. Nevertheless, it seems rational to kill or remove all transients on the hands of the surgeon and reduce residents to low levels. Surgical skin disinfection is usually assessed by measuring the reduction in organisms on the hands immediately after disinfection, after repeated applications of the disinfectant and after wearing gloves for two to three hours. The hands are commonly sampled in a bowl or plastic bag containing Ringer's or a similar solution and relevant neutralizers, or by the use of glove washings. A standardized technique is necessary to provide a statistical comparison between agents. Antiseptic detergents, chlorhexidine or povidone iodine show immediate reductions in bacterial counts of 70% to 80%, increasing to 99% after repeated application. Hexachloraphene and triclosan detergents show a lower immediate reduction but a good residual effect. Seventy percent ethyl or 60% propyl alcohol, with or without an antiseptic, show an immediate reduction of over 95%, and in excess of 99% on repeated application. Residual levels of organisms tend to be lower after repeated alcohol treatment than following the use of antiseptic detergents. A two to three-minute application of the antiseptic to the hands, without a scrubbing brush, is commonly recommended in the UK, but possibly in routine surgery an application time of 30 seconds is sufficient, killing or removing transients and superficial residents.