Ever since the mid-19th century when Ignaz Semmelweis discovered that infections during medical procedures can be caused by microorganisms on doctors' hands, hygiene before operations has become the standard.  However, the procedures and products used for this have constantly evolved.
While chlorine solutions were primarily used in the operating theatres of Semmelweis's day, 20th-century hospitals have frequently used antimicrobial soap to eliminate potential pathogens. Most hospitals still use these special soaps, which are often based on the ingredient chlorhexidine or chlorhexidine gluconate (CHG).
From hand washing to hand disinfection
Rub vs. Scrub: The difference
When we think of doctors preparing for surgery, our first image is usually of surgeons and nurses meticulously soaping their hands and forearms for minutes on end and then intensively "scrubbing" them. This is the so-called "scrub" method, which usually uses chlorhexidine-based antimicrobial soaps. On average, this procedure takes 5-6 minutes.
With the "rub" method, surgeons, doctors, and nurses no longer wash their hands for minutes in preparation of each procedure but disinfect them with alcohol-based hand disinfectants. In this scenario, medical personnel only wash their hands at the start of the working day or when the hands are visibly soiled. Before any actual procedures, staff take the following steps to disinfect their hands and arms.
- Removal of all jewellery (including wedding rings) and watches from the hands and forearms.
- Activation of the disinfectant dispenser lever with the elbow and wetting of both hands and forearms with sufficient hand disinfectant. The hands and forearms are rubbed thoroughly and kept wet for the entire contact time of 1.5 minutes.
- The process is repeated to ensure that all areas of the hands and forearms are thoroughly disinfected.
- Before putting on gloves, the disinfectant must dry completely.
Compared to antimicrobial hand washing, alcohol-based disinfection before operations offers several benefits to staff as well as facilities. Let's look at them.
Various studies have confirmed that frequent use of antimicrobial soap can lead to allergic skin reactions. The numbers speak for themselves: around one in five healthcare workers who regularly uses chlorhexidine-based products develops contact dermatitis. [2,3]
"My hands felt like they were on fire," Scottish nurse Thomas P. confirms. For years, he used chlorhexidine-based antimicrobial soap until he and his team discovered that the product was causing skin irritation and inflammation in many of them. "We now know that the skin reactions were due to the soap we used. Unfortunately, this diagnosis is not rare," says the nurse.
Over time, the situation became more and more unbearable for the caregiver. Thomas remembers, "Not only my hands were inflamed, but in some places even my forearms. It got so bad that my hands were bright red and I had to see a doctor." There was no improvement until his team switched to the rub method and used Sterillium® disinfectant instead of chlorhexidine-based soap. "Since then, I haven't had any skin reactions or inflammation. It saved my career!" says Thomas.
Science confirms the caregiver's experiences. Several studies show that alcohol-based hand disinfectants with a modern care complex cause significantly less skin irritation and dryness than soaps or antimicrobial detergents.  Since 2018, the U.S. Food and Drug Administration (FDA) has thus removed chlorhexidine from the list of products labelled "Generally Recognized as Safe and Effective". 
The decision for or against the scrub method also has a major influence on the environmental impact of healthcare facilities. Consider the fact that on average, staff spend 5-6 minutes washing their hands before operations. In many cases, they run the tap for the entire time. 
This means that around 20-40 litres of water are used per person for each procedure, even though only six litres are needed for the actual hand washing.  This shows how much water the scrub method wastes. Appropriate alternatives are therefore increasingly relevant. This is especially true in regard to climate change or in countries that have a limited water supply and that must pay increasing attention to limiting their water consumption.
The rub method can be an important component here. After all, much less water is needed to disinfect hands than to wash them. In an average hospital with about 15,000 operations a year, a transition to the rub method would save about one million litres of water. 
Switching to surgical hand disinfection also saves other resources as well. Staff no longer need many single-use paper towels or plastic brushes to wash their hands. These items can be eliminated from parts of the hospital’s inventory. And finally, the rub method uses less energy for heating the water used to wash hands. Hospitals that move from scrub to rub significantly reduce their carbon footprint. [9,10]
There’s a significant economic payoff for hospitals that switch from scrub to rub: lower costs for water and energy consumption, thousands of working hours saved per year and less downtime due to occupational skin diseases.
To be even more precise, facilities can save from around $280,000 to $348,000 per operating theatre per year.  This includes the costs of the operating room and personnel, water, towels, brushes, and water filters, if staff primarily disinfect their hands instead of washing them before every procedure. Surgical hand disinfection can thus save up to 67 per cent of costs. 
When hospitals decide in favour of the rub method, the effectiveness of the agent they choose is also decisive. The central question is whether hand disinfection can eliminate pathogens as reliably as scrubbing with antimicrobial soap?
Various studies have shown that disinfectants such as Sterillium® achieve comparable or even better results in reducing the microbial load than chlorhexidine-based soaps.  This is especially true in terms of long-term efficacy. After using an alcohol-based hand disinfectant, the reduction of the microbial load on the skin is still guaranteed after three or more hours. 
At the same time, bacteria are becoming increasingly resistant to chlorhexidine. Since this agent has been used for over 70 years, pathogens have had enough time to adapt to the active ingredient and develop strategies to withstand it.  Comparable resistance to purely alcoholic disinfectants, on the other hand, has not yet been observed.
 Stang A, Standl F, Poole C. A twenty-first century perspective on concepts of modern epidemiology in Ignaz Philipp Semmelweis' work on puerperal sepsis. Eur J Epidemiol. 2022 May;37(5):437-445. doi: 10.1007/s10654-022-00871-8. Epub 2022 Apr 29. PMID: 35486338; PMCID: PMC9209376.
 Stingeni L et al. (1995) Occupational hand dermatitis in hospital environments. Contact Dermatitis 33: 172-176. https://doi.org/10.1111/j.1600-0536.1995.tb00540.x
 Chiewchalermsri C et al. (2020) Chlorhexidine Allergy: Current Challenges and Future Prospects. J Asthma Allergy 13: 127-133. https://doi.org/10.2147%2FJAA.S207980
 World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care. 2009. https://www.who.int/publications/i/item/9789241597906 (accessed on January 4, 2023)
 FDA. FDA Drug Safety Communication FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. US Food and Drug Administration. 2022.
 Kampf et al 2006 Hyg Med 31:316-321
 Widmer AF (2013) Surgical hand hygiene: scrub or rub? J Hosp Infect 83 Suppl 1: S35-39. https://doi.org/10.1016/S0195-6701(13)60008-0 https://pubmed.ncbi.nlm.nih.gov/23453175/#:~:text=In%20the%20past%2C%20washing%20hands,less%20time%20than%20washing%20hands.
 Ahmed A. Surgical hand scrub: Lots of water wasted. Ann Afr Med 2007;6:31-3
 Javitt MJ et al (2020) Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost. JAMA Ophthalmol 138: 382–386. https://doi.org/10.1001/jamaophthalmol.2020.0048
 Tavolacci MP et al. (2006) Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs. J Hosp Infect 63: 55-59. https://doi.org/10.1016/j.jhin.2005.11.012
 Fry DE (2019) Operating Room Hand Preparation: To Scrub or to Rub? Surg Infect (Larchmt) 20: 129-134. https://doi.org/10.1089/sur.2018.302
 Kampf G, Ostermeyer C. Efficacy of two distinct ethanol-based hand rubs for surgical hand disinfection -- a controlled trial according to prEN 12791. BMC Infect Dis 5: 17. https://doi.org/10.1186/1471-2334-5-17
 Buxser S (2021) Has resistance to chlorhexidine increased among clinically-relevant bacteria? A systematic review of time course and subpopulation data. PLoS One 16: e0256336. https://doi.org/10.1371/journal.pone.0256336
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