Hajipour and co-workers recently evaluated two options for surgical hand antisepsis (3-minute hand wash with either chlorhexidine or alcohol gel) and concluded that the use of alcohol was associated with a higher risk of bacterial contamination of surgeons' hands and that it is not a suitable alternative to chlorhexidine when washing hands before surgery. Based on their research, I would be very reluctant to draw this conclusion and would like to address some major points of concern.
The end-point of their study is the number of colonies on agar plates after fingertip agar imprints obtained from surgeons' hands after taking off surgical gloves. Apparently, the agar did not contain any neutralising agents in order to inactivate residual chlorhexidine. This is a major scientific bias. Bacteria may well be present on a hand and transferred to the agar but may not multiply on it due to residual chlorhexidine in a bacteriostatic concentration leading to a significant overestimation of the efficacy of chlorhexidine.1 That is why I would consider all data obtained in the chlorhexidine group to be invalid.
It is also not acceptable to mention only ‘alcohol gel’. The efficacy of an alcohol-based hand rub depends on the type and concentration of alcohol, the application time and the viscosity.2 Many gels have a concentration of alcohol below 70% and have been described to be significantly less effective compared with rinses containing 75% alcohol or more.3 Well-formulated, alcohol-based hand rubs are also significantly more effective than antimicrobial soaps when tested with a 3-minute application time.4 In addition, well-formulated, alcohol-based hand rubs may reveal their efficacy within 1.5 minutes5 which may not even be achieved with some of the antimicrobial soaps in 3 minutes.4
There is much valid evidence in the literature that well-formulated, alcohol-based hand rubs provide a better and faster efficacy and a better dermal tolerance in comparison to antimicrobial soaps.2 I just hope that research with rather invalid methods does not encourage surgeons to go back to the secondbest option in surgical hand antisepsis.
Footnotes
COMMENT ON doi 10.1308/003588406X83032 L Hajipour, L Longstaff, V Cleeve, N Brewster, D Bint, P Henman. Hand washing rituals in trauma theatre: clean or dirty? Ann R Coll Surg Engl 2006; 88: 13–5
References
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