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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.45 no.6 São Paulo Dec. 2011 



The efficacy of three hand asepsis techniques using chlorhexidine gluconate (CHG 2%)


Eficacia de tres métodos de desinfección de las manos utilizando gluconato de clorhexidina antiséptica (GHC 2%)



Érika Rossetto da CunhaI; Fabiana Gonçalves de Oliveira Azevedo MatosII; Adriana Maria da SilvaIII; Eutália Aparecida Cândido de AraújoIV; Karine Azevedo São Leão FerreiraV; Kazuko Uchikawa GrazianoVI

IRN. MS in nursing, University of São Paulo, School of Nursing, Graduate Program. São Paulo, SP, Brazil.
IIDoctoral student, University of São Paulo, School of Nursing, Graduate Program. Member of the Studies Group "Control of Infection Related with Care Procedures". Professor, State University of West Paraná. Cascavel, PR, Brazil.
IIIDoctoral student, University of São Paulo, School of Nursing, Graduate Program. Member of the Studies Group "Control of Infection Related with Care Procedures". Ribeirão Preto, SP, Brazil.
IVProDoc Research Fellow/CAPES, University of São Paulo, Nursing School, Graduate Program in Adult Health Nursing (In Memoriam).
VRN. PhD, in Adult Health Nursing, University of São Paulo, Nursing School. Professor, Guarulhos University, Graduate Program. Researcher at the São Paulo State Cancer Institute, University of São Paulo. São Paulo, SP, Brazil.
VIFull professor, University of São Paulo, Nursing School, School of Nursing, Medical-Surgical Nursing Department. São Paulo, SP, Brazil.

Correspondence addressed to:




The scrubbing of hands and forearms using antiseptic agents has been the standard pre-operative procedure to prevent surgical site infection. With the introduction of antiseptic agents, the need to use brushes for pre-operative disinfection has been questioned and it has been recommended that the procedure be abandoned due to the injuries it may cause to the skin. With the purpose to provide the foundations for the efficacy of pre-operative asepsis without using brushes or sponges, the objective of this study was to evaluate three methods of pre-operative asepsis using an antimicrobial agent containing chlorhexidine gluconate - CHG 2%; hand-scrubbing with brush (HSB), hand-scrubbing with sponge (HSS), and hand-rubbing with the antiseptic agent (HRA) only. A comparative crossover study was carried with 29 healthcare providers. Antimicrobial efficacy was measured using the glove-juice method before and after each tested method. Statistical analyses showed there were no significant differences regarding the number of colony-forming units when comparing HRA, HSB, and HSS techniques (p=0.148), which theoretically disregards the need to continue using brushes or sponges for hand asepsis.

DESCRIPTORS: Handwashing; Chlorhexidine; Infection control; Surgical wound infection; Perioperative nursing.


La desinfección quirúrgica de manos y antebrazos es un procedimiento que integra las actividades prequirúrgicas como medida de prevención contra infección del sitio quirúrgico. Con el advenimiento de la antisepsia desinfectante, se cuestiona y se recomienda dejar de lado el uso de cepillos debido a lesiones provocadas en piel. Para fundamentar la eficacia de la técnica de desinfección quirúrgica sin uso de cepillos ni esponjas, se objetiva evaluar tres métodos de desinfección quirúrgica, usando la fórmula desinfectante de gluconato de clorhexidina-GHC 2% con cepillo, con esponja y sin adminículos. Fueron evaluados 29 profesionales de salud, usándose el método de caldo de guante para recolección de microorganismos antes y después de cada método probado. El análisis estadístico no comprobó diferencias significativas en la reducción microbiana entre los tres métodos (p=0,148), lo que teóricamente descarta la necesidad del uso de cepillos y esponjas para desinfección de manos.

DESCRIPTORES: Lavado de manos; Clorhexidina; Control de infecciones; Infección de herida operatória; Enfermería perioperatoria.




Hospital-acquired infections (HAI) represent a problem both in Brazil and in the world and constitute a risk to the health of hospital services users. Preoperative infections, currently called Surgical Site Infections (SSI), constitute a significant portion of the total of all these infections and are considered the second main cause of HAI(1). SSI prevention and control depends on health care workers adhering to preventive measures.

Among the SSI prevention practices, hand and forearm antisepsis for the surgical team members as a preoperative preparation began when Ignaz Semmelweis recommended the use of germicide to wash hands before examining pregnant women in 1847. Around 1860 Joseph Lister introduced the principles of asepsis in the practice of surgical procedures, substantially reducing the morbidity of patients in the postoperative period(2-3).

In addition to the fact that some gloves are permeable to bacteria, hand and forearm antisepsis is justified because gloves perforate at a rate of 18% at the end of surgeries and in more than 35% of these cases, perforations are not perceived by surgeons(4-5). Initially and for a long time, hand and forearm antisepsis technique included brushing with warm water and mild soap followed by immersing hands and forearms in antiseptic solution of iodine alcohol and then alcohol(6). However, the discomfort and risk of skin lesions caused by brushing can lead professionals to reduce the time of brushing, consequently reducing time of contact between the antiseptic and area to be cleaned, compromising the process of reducing microbial load. With the advent of antiseptic detergent solutions, the adverse effects of brushing could be minimized through the abolition of such a procedure and rubbing detergent solutions on the skin during the time required for the product to act, was adopted(3,7).

Despite innumerous international studies(3,8-14) contraindicating the use of artifacts for performing hand antisepsis, the studies found evaluated the efficiency of mechanical and chemical methods to perform hand antisepsis with the solution of chlorhexidine gluconate at 4% instead of 2%(4,9,15-17).

Since the brushing technique is still used in many Brazilian health facilities and considering that the chlorhexidine gluconate solution at 2% (GCH 2%) is one of the solutions most used in Brazilian facilities for surgical hand and forearm antisepsis, we decided to conduct this study to compare the efficiency of three antiseptic hand rub techniques to reduce microbial load using GCH 2%: rubbing with a disposable brush, a sponge, and without any artifacts.



Study's population

A total of 32 health workers were initially recruited. These were volunteers who met the following inclusion criteria: not regularly using antiseptic detergents in their daily activities to avoid causing cumulative or residual effects of any antiseptic active principle; and participating in a training program concerning hand and forearm antisepsis technique prior to data collection through formal theoretical practical teaching using a movie we had developed (TV and video).

Those using antibiotics or similar medication (topical or systemic) two weeks before or during data collection; those reporting previously known sensitivity to GCH; those with skin lesions on hands and/or forearms; those who were not able to reproduce the technique according to the standardized procedure; and those who did not complete the study were excluded.

Hand antisepsis protocol

The standard antisepsis technique was the same for the three tested methods. It was applied on the dominant hand given the belief that the motor skill of the non-dominant hand is diminished. Hence, we wanted to avoid conducting a worse-case scenarion investigation. Each volunteer performed the three antisepsis methods, while the first method was defined by a draw at the beginning of data collection. An interval of seven days between the collection of a specific method and another in the same volunteer was observed to allow skin microbiota to recover after antisepsis(6,8). Each volunteer took off any jewelry and hands and forearms were assessed to identify potential skin lesions.

The first collection of material for culture was performed on the dominant hand (It) according to the glove juice standard technique(8,18). The technique consisted of immersing the dominant hand of volunteers in sterile surgical gloves without talcum powder, purposely large (nº. 12) containing 150 ml of culture fluid tryptic soy broth with added 0.5% of Tween 80. The first solution is an enriched means to transport microbiological samples and the second is a means to neutralize any residue of GCH. One of the researchers rubbed the volunteers' gloved hands from the outside in a standardized manner for 60 seconds to promote a greater contact of the hands surface and the liquid(19). At the end of the procedure, the liquid from inside the glove (150ml) was aseptically transferred to a sterilized container with lid, which was immediately sent to the laboratory for bacteriological analyses. This procedure was repeated before (It) and after (Ft) the hands antisepsis procedure was performed in the three evaluated techniques.

Immediately after the collection of material in the initial time (It), each volunteer performed the standard antisepsis method on the dominant hand and forehand, beginning by the randomly selected method (with a brush, sponge or without any artifact). The antisepsis process was standardized by counting movements and not by counting time. The technique used was based on official guidelines(20-21).

After antisepsis was performed on the dominant hand and forearm, the volunteer waited 15 seconds to remove excess rinsing water by keeping the hand above the elbow level. After this period, the volunteers put on their sterilized surgical gowns, with fists pulled up with the middle third of the forearm to avoid accidental contamination during collection of microorganisms in the final time (Ft). Then, we performed microbiological collection from the dominant antiseptic hand, repeating the glove juice technique and the sequential steps already described.

Microbiological analyses

In the microbiological analysis laboratory, each collected sample was homogenized and quantitatively seeded with the aid of a calibrated loop; the plates contained blood agar and MacConkey agar. After sowing, the blood agar plates were incubated in a CO2 stove at 36ºC to promote the growth of anaerobic microorganisms, and the MacConkey agar at 36ºC for the growth of aerobic microorganisms, for 48 hours. After the incubation period, the colonies present in the plates were counted and the total number of colonies was multiplied by the factor of dilution (1:100) to define the total of colony-forming units per milliliter of sample (CFU/ml).

The equivalence of sample collection using a calibrated loop in place of a pipette was assessed using the Wilcoxon test and the Mann-Whitney test. No statistically significant differences were found between the two methods (p< 0.05), which validated the laboratory method of analysis.

Data analysis

The level of significance was fixed at 5% for the statistical analyzes. Statistics with p < 0.05 were considered significant. The dependent variable (microbial count) did not present normal distribution in the sponge antisepsis technique. These were normalized for the analysis and re-transformed in their measurement scale to present the results.

The analysis of variance for repeated measures using the GLM (generalized linear model) was used as a parametric statistical technique, which is a statistical procedure that incorporates normally distributed dependent variables and categorical or continuous independent variables.

To verify whether the microbiological counts of the three analyzed methods differ among them, the 2 x 2 multiple comparison was used. In this case, the level of significance takes into account the model's number of comparisons.

The power as a function of the sample size (n=49) for ANOVA with repeated measures, a continuous dependent variable (microbial count), alpha=0.05, bi-tailed test and continuity correction was 0.979.

Because this is a laboratory test, the study was exempted from submitting the project to the Ethics Research Committee. The opinion of the Ethics Research Committee at the University of São Paulo, School of Nursing is presented: In response to your request we inform you that the study entitled: 'Efficacy of three hands antisepsis techniques using chlorhexidine gluconate (GCH 2%)' does not require the approval of the Ethics Research Committee since it is of a laboratory nature with analysis of microorganisms, not involving human beings, in accordance with Resolution 196/96, National Council of Health.



Data collection was initially conducted using 32 professionals: 24 (75%) women and eight (25%) men, on average 43.3 years old (SD=7.4 years). Three of these were excluded: one was allergic to the antiseptic solution and the other two could not reproduce the antiseptic technique, totaling a sample of 29 volunteers. The samples of volunteers who presented initial microbial count equal to zero were also excluded because these did not allow establishing a parameter to compare microbial reduction after the antiseptic procedure. Similarly, those samples whose final microbial count (after antisepsis) was greater than the initial count (before antisepsis) were also excluded from the sample analyzes because they indicated accidental contamination of samples. This measure was based on the literature(22) to avoid compromising the results of the analyses.

The total number of analyzed samples was 49: 19 samples refer to the antiseptic technique with a brush, 10 refer to the antiseptic technique with a sponge, and 20 samples refer to the antiseptic technique without any artifact.

No statistically significant difference was found between the three tested methods (p=0.664), when the microbial load, measured by the number of colony-forming units, was compared before antisepsis of hands (It), suggesting the groups were homogenous (Figure 1).



The microbial load measured before and after each of the antiseptic methods was compared and a statistically significant (p<0.05) reduction was observed in the number of colony-forming units, suggesting the three techniques were efficacious in reducing the microbial count on hands and forearms (Table 1). This reduction was equivalent across methods, which can be verified in Table 2.



The analyses to evaluate the three tested methods, performed through parametric tests (GLM repeated measures), showed there was no statistically significant differences across the methods (p=0.148), permitting us to infer that the antiseptics methods are equivalent.

Similarity was observed among the different techniques in relation to the microbial agents isolated in the samples obtained after the antiseptic procedure. The main identified agent was negative Staphylococcus coagulase, followed by Corynebacterium spp and Micrococcus spp, which represent normal skin microbiota.



The results obtained in this study showed that the three tested antiseptic methods (rubbing with disposable brush, rubbing with sponge, and rubbing without any artifact) presented equivalent efficacy in reducing microbial contamination. Similar results were found in the literature concerning comparison of efficacy of the antiseptic method with or without the use of artifacts(3,8-15,23).

In addition to indicating that there are no additional advantages in the results of antisepsis performed with brush or sponge, there are studies also evidencing that rubbing hands without the use of artifacts is most cost-effective(4,9-10,24-25), describing better tolerance of skin when the antiseptic procedure is performed only using hands(10-17,24-29), and emphasizing that the active principle of the solution used and the rubbing movements performed with hands are the main factors in reducing the microbial load, regardless of the use of artifacts(3-4,8-9,17,24,26,28-30).

The laboratory investigation permitted controlling the variables, which conferred greater confidence in the results obtained. In spite of the methodological references used in this investigation, this study supports the possibility of excluding the use of artifacts in the antisepsis of hands and forearms of surgical teams using chlorhexidine gluconate at 2% within the scrub procedure, corroborating the cited international studies.

Even though there are innumerous international studies that do not recommend the use of artifacts while performing antisepsis of hands(4,9,15,17,26,28-29), there is still a large number of Brazilian professionals who do not adhere to the practice supported by this evidence.

We expect this study will contribute to a change in the Brazilian practice of hand antisepsis. To change such a practice, it is important to invest in continuing education programs, human resources training and in new scientific research(4,16,23,25); a lack of studies developed in the Brazilian context motivated this study.



The quantitative analyses of microorganism after surgical hand antisepsis (Ft) matched the efficacy of the three analyzed methods, which supports the possibility of excluding the use of disposable brushes in the preoperative antiseptic surgical hand scrub with GCH 2%, which was the active principle chosen in this experiment.



A limitation in this study related to putting the investigation method into operation is the possibility of error during the manipulation of samples in the scope of the microbiology laboratory when the initial microbial count was equal to zero or when the final count was greater than the initial count.

Another aspect that does not constitute a limitation in this study but raises questions is related to the residual effect of the studied surgical antisepsis and also the generalization of results for other detergent active principles such as polyvinylpyrrolidone iodine. The scope of this study was not broad given its focus, which was the need to investigate whether the use of artifacts such as brushes were indispensable for the studied practice.



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Correspondence addressed to:
Fabiana Gonçalves de Oliveira A Matos
Rua Monjoleiro, 125 - Tropical
CEP 85807-300 - Cascavel, PR, Brazil.

Received: 05/25/2010
Approved: 03/15/2011

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