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Surgical Scrub & Hand Antisepsis

Surgical hand antisepsis removes transient flora and lowers resident flora on the hands and forearms, and it slows regrowth under the glove. Its purpose is to limit contamination of the field when a glove is punctured. Glove perforation is common: about 30% of operations in one review.[1][2] This matters in long GU reconstructive cases and in any case that places a prosthesis or mesh, where a small skin-flora inoculum can matter. WHO accepts either a suitable antimicrobial soap-and-water scrub or a suitable surgical alcohol-based hand rub (ABHR) before donning sterile gloves (strong recommendation, moderate-quality evidence).[1] Gloves and hand antisepsis are complementary barriers.

Choose a Validated Surgical Method​

MethodExecutionImportant qualification
Antimicrobial soap-and-water scrubClean under the nails with a nail cleaner under running water. Scrub hands and forearms with chlorhexidine gluconate (CHG) or povidone-iodine for the labeled time, rinse, and dry with a sterile towel before gloving.WHO cites usual scrub times of 2–5 minutes, with product-specific instructions instead of a fixed first-case five-minute and later-case three-minute schedule; long scrubs (for example 10 minutes) are unnecessary.[1]
Surgical alcohol-based hand rubStart with clean, completely dry hands. Apply enough product to keep the hands and forearms wet for the whole validated application time, then let them dry fully before gloving.Use a product validated for surgical preparation (EN 12791, ASTM E-1115, or an equivalent standard). For US practice, SHEA/IDSA/APIC recommends an FDA-approved surgical hand scrub or rub (high-quality evidence). Volume, aliquots and time depend on the product; neither one fixed volume nor 90 seconds applies to every product.[1][2][3]

Do not perform a medicated scrub followed immediately by an alcohol rub. Residual moisture and the wash itself can impair the rub, so WHO advises against combining the two sequentially.[1] Wash with non-medicated soap on entering the operating area. Before a subsequent surgical alcohol rub, the German S2k guideline recommends an interval of >10 minutes after handwashing when feasible (recommendation degree ↑↑).[10] Between cases, repeat the rub or scrub without an additional prior handwash if hands remain clean. Wash and dry hands first if visibly soiled or after intervening work that risks bacterial-spore contamination; the German S2k guideline labels the latter instruction recommendation degree ↑.[1][10]

Product-Specific Times and Volumes​

Follow the label of the product in use. Examples from US labels:

Product (manufacturer label)Directions
Hibiclens (CHG 4%, Molnlycke)Wet hands and forearms; scrub for 3 minutes with about 5 mL (4 pumps) with a brush; rinse; repeat; dry thoroughly.[6]
Betadine Surgical Scrub (povidone-iodine 7.5%)Wet hands; spread about 5 mL over hands and forearms; scrub for 2.5–3 minutes (sponge optional); clean under the nails; add a little water for suds; rinse; repeat once with another 5 mL.[7]
Avagard (CHG 1% + ethanol 61% w/w, 3M/Solventum)On clean, dry hands, clean under the nails with a nail stick at the first use of the day. Use 2 mL for one hand and forearm, 2 mL for the other, then 2 mL for both hands to the wrists (three pumps in all). Allow to dry before gloving.[8]

Label directions differ from evidence-based practice on brushes: the Hibiclens label describes a brush, whereas WHO and SHEA advise a nail cleaner and no scrub brush. Alcohol-based products are flammable. The original WHO formulation II contains 75% v/v isopropanol with glycerol and hydrogen peroxide and failed at least one EN 12791 surgical-efficacy test condition.[11] WHO’s modified surgical formulation II uses 75% w/w isopropanol.[12] Commercial formulations vary, so use a preparation validated for surgical hand antisepsis and follow its labeled application time.[1][11][12]

Technique for an ABHR (three-aliquot method)​

The steps below are the Avagard label sequence; use the directions for the product being applied.[8]

  1. Apply the first aliquot to one palm, dip the opposite fingertips to treat under the nails, and spread it over that hand and forearm up to just above the elbow.
  2. Repeat for the other hand and forearm.
  3. Apply a final aliquot to both hands, with attention to the interdigital spaces and thumbs, up to the wrists.
  4. Let the hands dry completely before donning gown and gloves.[8][9]

Shortening the exposure below the validated time (for example, under 90 seconds for products validated at 90 seconds) sharply lowers bactericidal effect.[2]

Prepare Hands and Protect Skin​

  • Keep natural nails short. Remove hand and wrist jewelry, artificial nails and extenders. Scrubbed personnel who enter the sterile field should not wear nail polish or gel shellac.[1][3]
  • Clean visible subungual debris with a nail cleaner (not a brush), preferably under running water.[1]
  • Avoid scrub brushes; they damage skin.[3] Skin irritation and dermatitis occur with frequent scrubbing and are less frequent with ABHR and more frequent with iodophors. CHG can cause severe allergic reactions, including wheezing or shock; personnel with known CHG or ingredient allergy must use a different product.[6][8] With frequent antiseptic handwashing, CHG skin irritation is concentration-dependent; 4% CHG products are most likely to cause dermatitis.[1] Staff with dermatitis or suspected allergy need a compatible product. The German S2k guideline recommends covering inflammatory hand lesions with a pathogen-tight dressing after hand rub (recommendation degree ↑).[10] For a nonpurulent inflammatory hand lesion, surgery may be considered after risk assessment if a sterile film dressing is applied after surgical hand rub and before donning double surgical gloves (recommendation degree ↔).[10]
  • CHG labels warn against contact with eyes, ears and mouth. Serious, permanent eye injury can occur, and CHG can cause deafness if it reaches the middle ear through a perforated eardrum. After Avagard, avoid touching the eyes with treated hands.[6][8]
  • Wash visibly soiled hands with soap and water.[1][3] During Clostridioides difficile or norovirus outbreaks, SHEA/IDSA/APIC recommends encouraging soap-and-water washing after care of known or suspected cases, in addition to contact precautions (low-quality evidence); alcohol-based hand sanitizer should remain available.[3]
  • Dry hands completely before applying an alcohol rub after washing and before putting on sterile gloves.[1] Use facility-approved moisturizers that are compatible with antiseptics and gloves.[3]

Read the Evidence by Outcome​

Rub versus scrub. WHO found moderate-quality evidence of equivalence for surgical site infection (SSI) from three randomized trials comparing alcohol rubs with scrubs (PVP-I, CHG or plain soap). Some ABHR formulations lowered bacterial counts more than scrubs, but WHO treated that as indirect evidence.[1] The 2016 Cochrane review included 14 trials: four reported SSI and ten reported colony-forming units (CFUs). Most trials were small, but evidence quality ranged from very low to moderate across comparisons. The review found no firm evidence that one method lowers SSI more than another.[4] The Cochrane review reported four SSI comparisons, each from one trial:

  • Basic soap-and-water hygiene versus alcohol rub with hydrogen peroxide (3,317 enrolled; SSI assessed 30 days after discharge was 128/1,596 versus 127/1,537 among 3,133 analyzed): RR 0.97, 95% CI 0.77–1.23 (moderate-quality evidence).[4]
  • Alcohol-only rub for subsequent procedures versus aqueous scrub throughout the day (both arms scrubbed for the first procedure; 500 of 600 randomized patients analyzed; 30-day SSI): RR 0.56, 95% CI 0.23–1.34 (very low-quality evidence).[4]
  • Aqueous scrub versus alcohol rub with added active ingredients (4,387 patients; 30-day SSI 53/2,135 versus 55/2,252): RR 1.02, 95% CI 0.70–1.48 (low-quality evidence).[4]
  • Aqueous CHG brush scrub versus 61% ethanol plus 1% CHG rub (100 patients; one-month SSI 1/50 versus 2/50): RR 0.50, 95% CI 0.05–5.34 (low-quality evidence).[4]

Products and durations (CFU outcome only). Three Cochrane-included studies found CHG scrubs gave fewer CFUs than povidone-iodine scrubs. Of four CFU comparisons, three favored alcohol rubs with added active ingredients and one favored aqueous scrub; evidence ranged from moderate to very low quality. A 3-minute scrub reduced CFUs compared with a 2-minute scrub, on very low quality evidence. Whether a nail pick differs from a brush was unclear.[4]

Meta-analysis. A meta-analysis of seven trials in 764 healthcare workers found no statistically significant difference between rubbing and scrubbing in CFU counts or log reduction of CFU, after antisepsis or after surgery.[5] A validated ABHR is a reasonable default when shorter application and skin tolerance matter; WHO and SHEA also accept a suitable antimicrobial soap-and-water scrub.[1][2][3] The 2024 German S2k guideline recommends surgical ABHR without added antiseptic agents (recommendation degree ↑↑).[10] Correct execution and adherence to the label matter more than the choice of method.[1][2][5]

See Surgical Gloving and Patient Skin Antisepsis. Hand antisepsis is the surgeon-side complement of patient skin antisepsis; neither substitutes for the other.

References​

1. World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection. 2nd ed. 2018. Section 4.9: Surgical hand preparation. Guideline chapter.

2. Widmer AF. Surgical hand hygiene: scrub or rub? J Hosp Infect. 2013;83(Suppl 1):S35–S39. doi:10.1016/S0195-6701(13)60008-0

3. Glowicz JB, Landon E, Sickbert-Bennett EE, et al. SHEA/IDSA/APIC practice recommendation: strategies to prevent healthcare-associated infections through hand hygiene: 2022 update. Infect Control Hosp Epidemiol. 2023;44(3):355–376. doi:10.1017/ice.2022.304

4. Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2016;(1):CD004288. doi:10.1002/14651858.CD004288.pub3

5. Feng W, Lin S, Huang D, et al. Surgical hand rubbing versus surgical hand scrubbing: systematic review and meta-analysis of efficacy. Injury. 2020;51(6):1250–1257. doi:10.1016/j.injury.2020.03.007

6. Hibiclens (chlorhexidine gluconate 4%) solution, Molnlycke Health Care. Drug label. DailyMed.

7. Betadine Surgical Scrub (povidone-iodine 7.5%), Atlantis Consumer Healthcare. Drug label. DailyMed.

8. 3M Avagard (chlorhexidine gluconate 1% and ethyl alcohol 61% w/w) surgical hand antiseptic, Solventum. Drug label. DailyMed.

9. Khadaroo RG, Pilieci SN. Water-based and waterless surgical scrub techniques. N Engl J Med. 2023;389(10):e19. doi:10.1056/NEJMvcm1807798

10. Kramer A, Seifert J, Abele-Horn M, et al. "S2k-Guideline hand antisepsis and hand hygiene." GMS Hyg Infect Control. 2024;19:Doc42. doi:10.3205/dgkh000497

11. Suchomel M, Eggers M, Maier S, Kramer A, Dancer SJ, Pittet D. "Evaluation of World Health Organization–Recommended Hand Hygiene Formulations." Emerg Infect Dis. 2020;26(9):2064-2068. doi:10.3201/eid2609.201761

12. World Health Organization. Modified WHO Formulations for Surgical Hand Preparation. WHO technical sheet.