Surgical hand antisepsis to reduce surgical site infection一个考克兰系统评价

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Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004288.

Surgical hand antisepsis to reduce surgical site infection.

Tanner J, Swarbrook S, Stuart J.

Source

De Montfort University and University Hospitals Leicester, Charles Frears Campus, 266 London Road, Leicester, UK, LE2 1RQ. jtanner@dmu.ac.uk

AbstractBACKGROUND:

Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients.

OBJECTIVES:

To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH STRATEGY:

We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005).

SELECTION CRITERIA:

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS:

Three authors independently assessed studies for selection, trial quality and extracted data.

MAIN RESULTS:

Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.

AUTHORS' CONCLUSIONS:

Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.

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星梦78

背景
外科医师的手消毒可以降低病患手术部位之感染率
手术或是从事具侵袭性治疗步骤前，医謢人员需要良好的手部消毒步骤。这是因为它可以消灭或是抑制可能会藉由工作人员双手进入病患身体的微生物。也就是说，这个步骤应是可以降低病患手术部位之感染率的。
目标
为了证实医护人员良好的手部消毒步骤可以降低病患手术部位(简称SSI，Surgical Site Infection) 之感染率，与经消毒后这群医护人员手部残存的细菌菌落(CFUs，colony forming units) 数目(第二目标) 。
搜寻策略
作者们于以下不同的资料库中寻找与相关的资料，包括了: 考科蓝伤口小组的专业记录资料库(Cochrane Wounds Group Specialised Register，2007年6月) ，考科蓝受控试验登记纪录( Cochrane Central Register of Controlled Trials，Issue 2, 2007) ，线上医学分析与检索系统(MEDLINE，Week 5, 2007) ，护理与医疗相关文献资料库(CINAHL，June 2007) ，EMBASE医药学文献资料库(Week 23, 2007) ，与ZETOC全英图书电子化目录系统(2005) 。
选择标准
涵括手部消毒的步骤、时间长短与消毒溶液种类的随机性受控试验。
资料收集与分析
三位作者独立、分别地收集评估这些资料库中的试验报告与其品质，并分析其中的资料。
主要结论
经由检阅后，本文章共收录了十个不同的试验。其中仅有一试验提到了病患手术部位之感染率，其余九个则是报告了医护人员手部残存的细菌菌落数目。其中一个收集4387位病患的试验结果显示了医护人员不管是利用内含活性剂与酒精成分的消毒液或是水溶性刷手液来刷手，对于降低病患手术部位之感染率一样有效。四个试验比较不同成分但含酒精与活性剂的刷手液消毒和水溶性刷手液来刷手后，医护人员手部残存的细菌菌落数目。以下为这四个不同试验的结论: 1. 含有N?duopropenide的消毒液比含沙威隆(chlorhexidine) 和水溶性优碘的有效。 2. 含45% propanol?2、 30% propanol?1 与0.2% ethylhexadecyldimethyl ammonium ethylsulfate 的刷手液比只含沙威隆的有效。 3. 以61% 乙醇为主内含沙威隆葡萄糖酸盐(chlorhexidine gluconate) 或是以70% 为主内含zinc pyrithione的刷手液和水溶性优碘为主的刷手液比较并无差异。 4. 含4% 沙威隆葡萄糖酸盐的刷手液比以70% 酒精为主再加上沙威隆的刷手液有更佳的效果。此外，有另四个试验提出使用不同种类水性消毒液后，医护人员手部残存的细菌菌落数目：其中3个试验显示添加了沙威隆葡萄糖酸盐的溶液会比碘酒有较佳的结果。但是某一试验(在与碘酒加三氯沙?triclosan做比较后) 却找不出含沙威隆葡萄糖酸盐的溶液具有明显的优势。有两个试验认为若以菌落数目为依据，用含酒精成分的刷手液并不会影响结果。而有四个试验比较了刷手时间的长短与医护人员手部残存的细菌菌落数目之间的关系：其中某一试验发现在第二次刷手与使用沙威隆时，若能持续三分钟，其成效将远优于只刷三十秒。另一试验则显示了​​在一分钟的洗手后加上三分钟的刷手动作会比只用酒精类消毒液刷手五分钟有更低的菌落数。另外两个试验则认为无差异。
作者结论
在预防手术部位感染的成效上，使用含酒精的刷手液与水溶性的刷手液似乎是相同的。可惜的是，仅有一试验有如此的结论。在手部菌落数目上，四个试验则显示了​​含有酒精的刷手液效果似乎不会比水溶性刷手液来的差。而不同种类的刷手液(含酒精) 效力则相差不远。只是对于分析这四个品质高低不一、比较的溶液也均不相同的试验结果而言，此结论是具有一定误差的。至于含沙威隆葡萄糖酸盐的水性溶液是比只含碘酒的水性溶液可以降低更多的细菌菌落数。而刷手时间长短则是不具太大的影响力的。除此之外，这些试验无法提出刷具种类(刷子或海棉) 与刷手成效相关的证据。
翻译人
本摘要由成功大学附设医院林劭洁翻译。
此翻译计画由台湾国家卫生研究院(National Health Research Institutes, Taiwan) 统筹。
总结
良好的手部消毒步骤是可以降低病患手术部位感染率。医护人员常规使用消毒液(刷手或是手部搓揉剂) 来刷(洗) 手，借此降低风险。添加活性剂的酒精手部搓揉剂与水溶性刷手液在减少手术部位感染方面没有差异。不过一些评估手术前后菌落数的研究发现使用水溶性刷手液Chlorhexidine在减少菌落数方面较优碘有效。比较水溶性刷手液与含有添加活性成分的酒精搓揉剂的证据不一，来自研究的证据显示两种形式的消毒液都可以采用。