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Surgical Scrub & Hand Antisepsis

Surgical hand antisepsis reduces the resident and transient skin flora of the operating team's hands and forearms before gloving, so that an intraoperative glove perforation does not seed the wound.[1] The reconstructive relevance is the same as for gloving: GU reconstructive cases are often long (more time for glove failure), many place a prosthesis (artificial urinary sphincter, penile prosthesis, mesh) where skin-flora contamination is consequential, and urologic procedures carry a high measured glove-perforation rate. Both a traditional water-based scrub and a waterless alcohol-based hand rub (ABHR) are acceptable — multiple systematic reviews and the WHO find no difference in surgical-site-infection (SSI) rates between them.[1][2][3]

See also: Surgical Draping & Skin Antisepsis (the patient-side antisepsis step), Surgical Gloving.

The Two Accepted Techniques​

1. Traditional Water-Based Surgical Scrub​

  • Pre-wash with soap and water to remove visible soil; clean under the nails with a nail pick under running water — not a brush.[3]
  • Apply an antimicrobial agent — chlorhexidine gluconate (CHG) or povidone-iodine — and scrub hands and forearms systematically.
  • Duration: a minimum of 2 minutes is supported by evidence; manufacturer instructions and some guidelines specify 2–5 minutes. A common protocol is up to 5 minutes for the first scrub of the day and ~3 minutes for subsequent scrubs.[3][4]
  • CHG may be preferred over povidone-iodine for greater colony-forming-unit (CFU) reduction on the hands, though the clinical significance for SSI rates is uncertain.[3][4][5]

2. Waterless Alcohol-Based Hand Rub (ABHR)​

  • Dispense 4–6 mL per application (more for larger hands); the skin must stay visibly wet for the entire rub.[5]
  • Apply systematically — a typical three-aliquot technique covers (1) one hand and forearm fingertips-to-elbow, (2) the opposite hand and forearm, and (3) both hands with attention to the interdigital spaces and thumbs.[6]
  • Some formulations are validated at as little as 90 seconds, but technique and timing are critical — dropping below the validated exposure time significantly reduces efficacy.[7]
  • ABHR causes less skin damage and may reduce bacterial shedding compared with scrubbing.[2][5]

Principles Common to Both Techniques​

  • No scrub brushes. They damage skin and paradoxically increase bacterial shedding.[3][5]
  • Remove artificial nails, nail extenders, and chipped polish — each is associated with higher contamination / infection risk.[4][5]
  • Soap and water — not ABHR — when hands are visibly soiled or after Clostridioides difficile exposure (alcohol does not kill spores).[4]
  • For routine, non-surgical hand hygiene, a minimum of 15 seconds of rub or wash applies.[4][5]

Bottom Line​

A meta-analysis of 7 trials (764 healthcare workers) found no statistically significant difference in CFU counts between surgical hand rubbing and scrubbing.[2] Given equivalent efficacy, ABHR is increasingly recommended as a cost-effective default — faster, easier to apply, and less irritating to the skin — with the water-based scrub remaining fully acceptable.[2][7] Hand antisepsis is the surgeon-side complement to patient skin antisepsis; both are required, neither substitutes for the other.

References​

1. Allegranzi B, Bischoff P, de Jonge S, et al. "New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective." Lancet Infect Dis. 2016;16(12):e276–e287. doi:10.1016/S1473-3099(16)30398-X

2. 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

3. 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

4. Provenzano DA, Hanes M, Hunt C, et al. "ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine." Reg Anesth Pain Med. 2025;rapm-2024-105651. doi:10.1136/rapm-2024-105651

5. 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

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

7. 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