Surgical Scrubbing With Versus Without a Brush for Reducing Bacterial Hand Colonization: A Literature Review

Fredrick Wambu

The Nairobi Hospital

Presentation

• Background
• Objective
• Methods
• Results
• Discussion
• Conclusion
• References

Effect of surgical scrubbing with an antiseptic and a scrub brush compared to surgical hand preparation with antiseptic soap alone without a brush on hand bacterial colony counts and skin integrity immediately after the scrub

Scrubbing without a brush

Scrubbing using a sterile brush

Background

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• Globally over 300 million operations performed globally (WHO 2025)
• OR Personnel perform billions of surgical hand scrub annually- Globally
• Purpose- remove debris and transient microorganisms from the nails, hands, and forearms.
• Reduce the resident microbial count to a minimum- inhibit rapid rebound

growth of microorganisms

• Optimal surgical hand scrub procedure- debated by researchers all over

the world.-Audits and Feedback

• CDC- usage of nail picks, but not nail brush, to clean underside of nails during

surgical scrub

• Significant gap remains between guidelines and actual practice-no standard universal protocol

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General guidelines

• Rings, watches, and bracelets should be removed before beginning the surgical hand scrub
• Fingernails must be kept short, clean, and healthy
• Artificial nails should not be worn.
• Effective antimicrobial surgical hand scrub agent approved by the health care facility should be used for all surgical hand scrubs
• If brushes are used the selection of reusable or disposable brushes or sponges - based on realistic considerations
• Surgical hand scrub procedure- standardized for all personnel (Policy &procedure)

Objective

• To compare surgical scrubbing with and without use of a sterile brush by analyzing the effect on bacteria count on the hand
• Literature review -2020-2025
• 5 Randomized clinical trials
• Evidence synthesis

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Methods

• Prospective randomized controlled clinical trials comparing the effectiveness of surgical scrubs with brush (intervention group) and without brush (control group) with bacterial colony forming unit count as reference standard.
• Bacterial colony on hands swab measurements taken before surgical hand preparation (pre-test), immediately after surgical hand preparation (post-test 2), and immediately after the surgery procedures were completed (post-test 3).
• Population –OR Nurses and surgeons

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Methods and materials –Hand swabs

• Hand swab in all fingertips area; (c) Hand swab in interdigit area; (d) Hand swab in dorsal area; (e) Hand swab in ventral area.

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Results

• Surgical scrub with brush shows 44.7% reduction of bacterial colony forming units
• Surgical scrub without brush shows 25.9% reduction, although there are no significant difference statistically between the two groups (p = 0.151).
• No statistically significant difference in bacterial reduction between scrubbing with a brush versus using antiseptic soap alone.
• This shows that both approaches are equally effective in reducing bacterial colony forming units count.

Discussion

• Repetitive mechanical brushing compromises the epidermal barrier, causing micro-abrasions and potentially increasing bacterial shedding
• WHO guideline on Hand Hygiene in Health care allows the use of brush but only for nails and cuticles, only when it looks dirty, however the brush must be sterile and disposable

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Conclusions

• Surgical scrub procedure with or without the use of brush effectively reduce the number of hand bacterial flora. (Nieves etal.,2024)
• The addition of brush to surgical scrub routines do not provide significant benefit in reducing hand bacterial flora.
• The use of brush is recommended for dirty nail and cuticles, however it must be a single use and disposable.( Serra et al.,2023)

Limitations

• 5 RCT Reviewed were single-setting study – Limits generalization
• Paucity of local studies- None in Kenya. Local data is critical
• Use of disposable versus reusable sterile brushes
• Further research with multiple settings and a broader scope of participants and types of surgery is warranted to obtain more generalizable and representative results.

Take home message

• Choice of method- to use a brush or not must also consider the policies that apply in the institution so that the process runs in line with the rules that have been set.
• Flexibility in choosing to use a brush or not is possible as long as the standard hand scrubbing procedures are accurately followed to ensure the ultimate goal is achieved.

References

• World Health Organization. WHO guidelines on hand hygiene in health care. First global patient safety challenge: clean care is safer care. Geneva [Switzerland]: World Health Organization; 2009. p. 54-153.
• Nthumba, P.M. Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries. Surg. Infect. 2020, 21, 495–500. [Google Scholar] [CrossRef] [Scilit]
• Gök, F. Surgical hand washing: A systematic review. Int. J. Antiseps. Disinfect. Steriliz. 2016, 1, 23–32. [Google Scholar] [CrossRef] [Scilit]

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References

• Nieves, V.; Gundersen, T.; Mykkeltveit, I. The surgical team’s adherence to recommended guidelines for surgical hand preparation: A quantitative observation study. Sykepl. Forsk. 2024, 15, 123–130. [Google Scholar] [CrossRef] [Scilit]
• Sharif, B.O.; Edan, S.M.; Saeed, B.I.; Kaka, A.K. Evaluation of the Theater Staff Performance Regarding Surgical Hand scrub at Rania Teaching Hospital. Int. J. Med. Sci. Nurs. Res. 2022, 2, 18–24. [Google Scholar] [CrossRef] [Scilit]
• Serra Neto, A.; Marques, S.G.; Bomfim, M.R.Q.; Monteiro, S.G.; de Souza, R.C.; Nunes, R.A. Microbiological Analysis of Surgeons’ Hands in a Public Hospital in São Luis, Maranhão State, Brazil: A Cross-Sectional Study. Microorganisms 2023, 11, 1895

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