Optimierung der chirurgischen Händedesinfektion in einer Pferdeklinik: Einfluss der Durchführungstechnik auf die Keimreduktion

Einleitung: Die Hände des medizinischen Personals gelten als wichtigste Übertragungsquelle von Krankheitserregern. Methicillin- und multiresistente Erreger stellen die Tiermedizin vor besondere Herausforderungen und limitieren therapeutische Optionen. Obwohl die chirurgische Händedesinfektion einen wichtigen und alltäglichen Bestandteil der Infektionsprävention darstellt, scheinen die Grundkenntnisse hierüber selbst bei chirurgischen Fachtierärzten gering zu sein. Studien haben gezeigt, dass 66 % der Chirurgen sich nicht an etablierte Standardprotokolle halten. Neben der Händedesinfektion stellen sterile OP-Handschuhe eine zusätzliche Barriere für die Übertragung von Bakterien dar. Allerdings sind perforierte Handschuhe mit einem höheren Risiko für postoperative Infektionen (SSI) verbunden, wobei die SSI-Rate in der Pferdechirurgie bis über 60 % reicht. Ziele der Untersuchungen: Die Hauptziele dieser Arbeit lagen in der Erhebung der individuellen Gewohnheiten bei der Durchführung der chirurgischen Händedesinfektion in einer Pferdeklinik (Phase 1) und dem Vergleich der Keimreduktion mit einem Standardprotokoll (Phase 2). Ferner wurden die Proben auf Bakterienspezies gescreent, die SSI induzieren können. Darüber hinaus wurde die Rate von Handschuhperforationen bestimmt. Material und Methoden: Die Observation der individuellen Gewohnheiten (Phase 1) umfasste die Dauer der Händewaschung und -desinfektion, die genutzte Desinfektionsmittelmenge und Zusammenfassung 62 die Verwendung von Bürsten. Das Standardprotokoll in Phase 2 beinhaltete eine 1-minütige Händewaschung mit flüssiger, pH-neutraler Seife ohne Bürsten und die Händedesinfektion über 3 Minuten. Alle Teilnehmer (2 Chirurgen, 8 Klinikmitarbeiter, 32 Studenten) verwendeten Sterillium® für die Händedesinfektion. Die Gesamtkeimzahlen wurden jeweils vor und nach dem Händewaschen, nach der Desinfektion und nach der Operation bestimmt. Zur Probennahme wurden die Hände für 1 Minute in 100 ml sterile phosphatgepufferte Lösung getaucht und die Bakterienkulturen auf Columbia-Schafblutagar angezüchtet. Die Bakterienkolonien wurden manuell ausgezählt und die Bakterienspezies mittels MALDI-TOF identifiziert. Die Handschuhe wurden postoperativ mit einem modifizierten Wasser-Leck-Test auf Perforationen untersucht. Ergebnisse: In Phase 1 und Phase 2 wurden 46 bzw. 41 Händedesinfektionen durchgeführt. Die individuellen Gewohnheiten unterschieden sich deutlich zwischen den Teilnehmern hinsichtlich der Dauer des Händewaschens (bis zu 8 min) und der Desinfektion, sowie der Menge des verwendeten Desinfektionsmittels (bis zu 48 ml). Die Dauer des Händewaschens in Phase 1 und 2 zeigte keinen statistisch signifikanten Effekt auf die Bakterienreduktion. Bei Verwendung des Standardprotokolls war die Reduktion der Keimzahlen nach der Desinfektion im Vergleich zur täglichen Routine signifikant höher (p 60 Minuten vorlag. Die Mehrheit (85 %) der Perforationen blieben vom Operationsteam unbemerkt, wobei Zeigefinger und Daumen die am häufigsten punktierten Stellen waren. Insgesamt nahmen die Bakterienzahlen an den Händen im Laufe der Zeit erneut zu, insbesondere wenn eine Handschuhperforation auftrat. Schlussfolgerung: Die Einhaltung eines Standardprotokolls nach neuestem Stand der Wissenschaft trägt zu einer quantitativ höheren und gleichmäßigeren Keimreduktion beider Hände bei. Die Implementierung eines standardisierten Händedesinfektionsplans sichert die Qualität der aseptischen Maßnahme und ist besonders für die Ausbildung und Schulung von Studenten mit geringer chirurgischer Erfahrung unerlässlich.:1 Einleitung ............................................................................................................................ 1 2 Literaturübersicht ............................................................................................................... 3 2.1 Residente und transiente Hautflora ............................................................................. 3 2.2 Asepsis und Antisepsis ............................................................................................... 4 2.3 Grundlagen und allgemeine Voraussetzungen für eine effektive Händehygiene ......... 4 2.4 Händewaschung .......................................................................................................... 5 2.4.1 Limitationen der Händewaschung ........................................................................ 5 2.5 Händedesinfektion ....................................................................................................... 6 2.5.1 Historie der Händedesinfektion ............................................................................ 6 2.5.2 Hygienische Händedesinfektion ........................................................................... 8 2.5.3 Chirurgische Händedesinfektion .......................................................................... 8 2.5.4 Aliphatische Alkohole ......................................................................................... 10 2.5.5 Dauer und Wirksamkeit der chirurgischen Händedesinfektion .......................... 12 2.5.6 Compliance ........................................................................................................ 13 2.5.7 Zulassung und Prüfung von Händedesinfektionsmitteln .................................... 15 2.6 Nosokomiale Infektionen, Surgical Site Infections (SSI) ........................................... 16 2.6.1 Staphylococcus aureus ...................................................................................... 18 2.6.1.1 Methicillin-resistente Staphylococcus aureus (MRSA) ................................... 18 2.7 Handschuhe .............................................................................................................. 21 2.7.1 Nutzen und Limitationen von Handschuhen ...................................................... 21 3 Veröffentlichung ............................................................................................................... 24 3.1 Eigenanteil zur Veröffentlichung ................................................................................ 24 3.1.1 Publikation ......................................................................................................... 26 4 Diskussion ........................................................................................................................ 50 5 Zusammenfassung ........................................................................................................... 61 6 Summary .......................................................................................................................... 63 7 Literaturverzeichnis .......................................................................................................... 65 Danksagung .............................................................................................................................. 79Introduction: Hands of medical personnel are considered the most important source of pathogen transmission. Methicillin- and multiresistant strains of pathogens provide particular challenges to veterinary medicine and limit therapeutic options. Surgical hand disinfection is a major aspect of infection prevention, but basic knowledge seems to be low, even among specialized veterinary surgeons. Studies revealed that 66 % of surgeons do not adhere to established standard protocols. Besides hand disinfection, sterile surgical gloves provide an additional barrier to the transmission of bacteria. However, perforated gloves are associated with a higher risk of surgical site infections (SSI), with an SSI rate in equine surgery exceeding 60 %. Objective: The major objectives were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary equine hospital and to compare the effectiveness in reducing bacteria from hands with a standardized protocol (phase 2). Moreover, samples were screened for bacteria known to cause surgical site infection. The rate of glove perforation was determined, additionally. Material and methods: Individual habits were recorded with regards to the time taken for washing and disinfecting hands, the amount of disinfectant used, as well as the usage of brushes (Phase 1). In contrary to the personal habits, the applied standardized protocol (Phase 2) defined washing hands for 1 minute with liquid neutral soap without brushing and disinfection for Summary 64 3 minutes. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium® for disinfection. Total bacterial counts were determined before and after hand washing, after disinfection and after surgery. In brief, hands were immersed in 100 ml sterile phosphate-buffered saline for 1 minute and cultures were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Surgical gloves were investigated for perforations after surgery using a modified water leak test. Results: Fourty-six and 41 hand disinfection preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly between participants regarding the duration of handwashing (up to 8 min) and disinfection as well as the amount of disinfectant used (up to 48 ml). The duration of hand washing in phase 1 and 2 revealed no statistically significant effect on reducing bacteria. In contrary, using the standardized protocol in phase 2, reduction in bacterial numbers after disinfection was significantly higher (p 60 minutes. The majority (85 %) of perforations was unnoticed by the surgical team, with index fingers and thumbs most frequently affected. Overall, bacterial numbers on hands mainly increased over time during surgery, especially when glove perforation occurred. Conclusion: Adherence to state-of-the-art standardized protocols contributes to a quantitatively higher and constant germ reduction on both hands. The implementation of a standardized hand disinfection protocol ensures a high quality of aseptic measures and is essential for the education and training of students with little surgical experience.:1 Einleitung ............................................................................................................................ 1 2 Literaturübersicht ............................................................................................................... 3 2.1 Residente und transiente Hautflora ............................................................................. 3 2.2 Asepsis und Antisepsis ............................................................................................... 4 2.3 Grundlagen und allgemeine Voraussetzungen für eine effektive Händehygiene ......... 4 2.4 Händewaschung .......................................................................................................... 5 2.4.1 Limitationen der Händewaschung ........................................................................ 5 2.5 Händedesinfektion ....................................................................................................... 6 2.5.1 Historie der Händedesinfektion ............................................................................ 6 2.5.2 Hygienische Händedesinfektion ........................................................................... 8 2.5.3 Chirurgische Händedesinfektion .......................................................................... 8 2.5.4 Aliphatische Alkohole ......................................................................................... 10 2.5.5 Dauer und Wirksamkeit der chirurgischen Händedesinfektion .......................... 12 2.5.6 Compliance ........................................................................................................ 13 2.5.7 Zulassung und Prüfung von Händedesinfektionsmitteln .................................... 15 2.6 Nosokomiale Infektionen, Surgical Site Infections (SSI) ........................................... 16 2.6.1 Staphylococcus aureus ...................................................................................... 18 2.6.1.1 Methicillin-resistente Staphylococcus aureus (MRSA) ................................... 18 2.7 Handschuhe .............................................................................................................. 21 2.7.1 Nutzen und Limitationen von Handschuhen ...................................................... 21 3 Veröffentlichung ............................................................................................................... 24 3.1 Eigenanteil zur Veröffentlichung ................................................................................ 24 3.1.1 Publikation ......................................................................................................... 26 4 Diskussion ........................................................................................................................ 50 5 Zusammenfassung ........................................................................................................... 61 6 Summary .......................................................................................................................... 63 7 Literaturverzeichnis .......................................................................................................... 65 Danksagung .............................................................................................................................. 7

Optimierung der chirurgischen Händedesinfektion in einer Pferdeklinik: Einfluss der Durchführungstechnik auf die Keimreduktion

Einleitung: Die Hände des medizinischen Personals gelten als wichtigste Übertragungsquelle von Krankheitserregern. Methicillin- und multiresistente Erreger stellen die Tiermedizin vor besondere Herausforderungen und limitieren therapeutische Optionen. Obwohl die chirurgische Händedesinfektion einen wichtigen und alltäglichen Bestandteil der Infektionsprävention darstellt, scheinen die Grundkenntnisse hierüber selbst bei chirurgischen Fachtierärzten gering zu sein. Studien haben gezeigt, dass 66 % der Chirurgen sich nicht an etablierte Standardprotokolle halten. Neben der Händedesinfektion stellen sterile OP-Handschuhe eine zusätzliche Barriere für die Übertragung von Bakterien dar. Allerdings sind perforierte Handschuhe mit einem höheren Risiko für postoperative Infektionen (SSI) verbunden, wobei die SSI-Rate in der Pferdechirurgie bis über 60 % reicht. Ziele der Untersuchungen: Die Hauptziele dieser Arbeit lagen in der Erhebung der individuellen Gewohnheiten bei der Durchführung der chirurgischen Händedesinfektion in einer Pferdeklinik (Phase 1) und dem Vergleich der Keimreduktion mit einem Standardprotokoll (Phase 2). Ferner wurden die Proben auf Bakterienspezies gescreent, die SSI induzieren können. Darüber hinaus wurde die Rate von Handschuhperforationen bestimmt. Material und Methoden: Die Observation der individuellen Gewohnheiten (Phase 1) umfasste die Dauer der Händewaschung und -desinfektion, die genutzte Desinfektionsmittelmenge und Zusammenfassung 62 die Verwendung von Bürsten. Das Standardprotokoll in Phase 2 beinhaltete eine 1-minütige Händewaschung mit flüssiger, pH-neutraler Seife ohne Bürsten und die Händedesinfektion über 3 Minuten. Alle Teilnehmer (2 Chirurgen, 8 Klinikmitarbeiter, 32 Studenten) verwendeten Sterillium® für die Händedesinfektion. Die Gesamtkeimzahlen wurden jeweils vor und nach dem Händewaschen, nach der Desinfektion und nach der Operation bestimmt. Zur Probennahme wurden die Hände für 1 Minute in 100 ml sterile phosphatgepufferte Lösung getaucht und die Bakterienkulturen auf Columbia-Schafblutagar angezüchtet. Die Bakterienkolonien wurden manuell ausgezählt und die Bakterienspezies mittels MALDI-TOF identifiziert. Die Handschuhe wurden postoperativ mit einem modifizierten Wasser-Leck-Test auf Perforationen untersucht. Ergebnisse: In Phase 1 und Phase 2 wurden 46 bzw. 41 Händedesinfektionen durchgeführt. Die individuellen Gewohnheiten unterschieden sich deutlich zwischen den Teilnehmern hinsichtlich der Dauer des Händewaschens (bis zu 8 min) und der Desinfektion, sowie der Menge des verwendeten Desinfektionsmittels (bis zu 48 ml). Die Dauer des Händewaschens in Phase 1 und 2 zeigte keinen statistisch signifikanten Effekt auf die Bakterienreduktion. Bei Verwendung des Standardprotokolls war die Reduktion der Keimzahlen nach der Desinfektion im Vergleich zur täglichen Routine signifikant höher (p 60 Minuten vorlag. Die Mehrheit (85 %) der Perforationen blieben vom Operationsteam unbemerkt, wobei Zeigefinger und Daumen die am häufigsten punktierten Stellen waren. Insgesamt nahmen die Bakterienzahlen an den Händen im Laufe der Zeit erneut zu, insbesondere wenn eine Handschuhperforation auftrat. Schlussfolgerung: Die Einhaltung eines Standardprotokolls nach neuestem Stand der Wissenschaft trägt zu einer quantitativ höheren und gleichmäßigeren Keimreduktion beider Hände bei. Die Implementierung eines standardisierten Händedesinfektionsplans sichert die Qualität der aseptischen Maßnahme und ist besonders für die Ausbildung und Schulung von Studenten mit geringer chirurgischer Erfahrung unerlässlich.:1 Einleitung ............................................................................................................................ 1 2 Literaturübersicht ............................................................................................................... 3 2.1 Residente und transiente Hautflora ............................................................................. 3 2.2 Asepsis und Antisepsis ............................................................................................... 4 2.3 Grundlagen und allgemeine Voraussetzungen für eine effektive Händehygiene ......... 4 2.4 Händewaschung .......................................................................................................... 5 2.4.1 Limitationen der Händewaschung ........................................................................ 5 2.5 Händedesinfektion ....................................................................................................... 6 2.5.1 Historie der Händedesinfektion ............................................................................ 6 2.5.2 Hygienische Händedesinfektion ........................................................................... 8 2.5.3 Chirurgische Händedesinfektion .......................................................................... 8 2.5.4 Aliphatische Alkohole ......................................................................................... 10 2.5.5 Dauer und Wirksamkeit der chirurgischen Händedesinfektion .......................... 12 2.5.6 Compliance ........................................................................................................ 13 2.5.7 Zulassung und Prüfung von Händedesinfektionsmitteln .................................... 15 2.6 Nosokomiale Infektionen, Surgical Site Infections (SSI) ........................................... 16 2.6.1 Staphylococcus aureus ...................................................................................... 18 2.6.1.1 Methicillin-resistente Staphylococcus aureus (MRSA) ................................... 18 2.7 Handschuhe .............................................................................................................. 21 2.7.1 Nutzen und Limitationen von Handschuhen ...................................................... 21 3 Veröffentlichung ............................................................................................................... 24 3.1 Eigenanteil zur Veröffentlichung ................................................................................ 24 3.1.1 Publikation ......................................................................................................... 26 4 Diskussion ........................................................................................................................ 50 5 Zusammenfassung ........................................................................................................... 61 6 Summary .......................................................................................................................... 63 7 Literaturverzeichnis .......................................................................................................... 65 Danksagung .............................................................................................................................. 79Introduction: Hands of medical personnel are considered the most important source of pathogen transmission. Methicillin- and multiresistant strains of pathogens provide particular challenges to veterinary medicine and limit therapeutic options. Surgical hand disinfection is a major aspect of infection prevention, but basic knowledge seems to be low, even among specialized veterinary surgeons. Studies revealed that 66 % of surgeons do not adhere to established standard protocols. Besides hand disinfection, sterile surgical gloves provide an additional barrier to the transmission of bacteria. However, perforated gloves are associated with a higher risk of surgical site infections (SSI), with an SSI rate in equine surgery exceeding 60 %. Objective: The major objectives were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary equine hospital and to compare the effectiveness in reducing bacteria from hands with a standardized protocol (phase 2). Moreover, samples were screened for bacteria known to cause surgical site infection. The rate of glove perforation was determined, additionally. Material and methods: Individual habits were recorded with regards to the time taken for washing and disinfecting hands, the amount of disinfectant used, as well as the usage of brushes (Phase 1). In contrary to the personal habits, the applied standardized protocol (Phase 2) defined washing hands for 1 minute with liquid neutral soap without brushing and disinfection for Summary 64 3 minutes. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium® for disinfection. Total bacterial counts were determined before and after hand washing, after disinfection and after surgery. In brief, hands were immersed in 100 ml sterile phosphate-buffered saline for 1 minute and cultures were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Surgical gloves were investigated for perforations after surgery using a modified water leak test. Results: Fourty-six and 41 hand disinfection preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly between participants regarding the duration of handwashing (up to 8 min) and disinfection as well as the amount of disinfectant used (up to 48 ml). The duration of hand washing in phase 1 and 2 revealed no statistically significant effect on reducing bacteria. In contrary, using the standardized protocol in phase 2, reduction in bacterial numbers after disinfection was significantly higher (p 60 minutes. The majority (85 %) of perforations was unnoticed by the surgical team, with index fingers and thumbs most frequently affected. Overall, bacterial numbers on hands mainly increased over time during surgery, especially when glove perforation occurred. Conclusion: Adherence to state-of-the-art standardized protocols contributes to a quantitatively higher and constant germ reduction on both hands. The implementation of a standardized hand disinfection protocol ensures a high quality of aseptic measures and is essential for the education and training of students with little surgical experience.:1 Einleitung ............................................................................................................................ 1 2 Literaturübersicht ............................................................................................................... 3 2.1 Residente und transiente Hautflora ............................................................................. 3 2.2 Asepsis und Antisepsis ............................................................................................... 4 2.3 Grundlagen und allgemeine Voraussetzungen für eine effektive Händehygiene ......... 4 2.4 Händewaschung .......................................................................................................... 5 2.4.1 Limitationen der Händewaschung ........................................................................ 5 2.5 Händedesinfektion ....................................................................................................... 6 2.5.1 Historie der Händedesinfektion ............................................................................ 6 2.5.2 Hygienische Händedesinfektion ........................................................................... 8 2.5.3 Chirurgische Händedesinfektion .......................................................................... 8 2.5.4 Aliphatische Alkohole ......................................................................................... 10 2.5.5 Dauer und Wirksamkeit der chirurgischen Händedesinfektion .......................... 12 2.5.6 Compliance ........................................................................................................ 13 2.5.7 Zulassung und Prüfung von Händedesinfektionsmitteln .................................... 15 2.6 Nosokomiale Infektionen, Surgical Site Infections (SSI) ........................................... 16 2.6.1 Staphylococcus aureus ...................................................................................... 18 2.6.1.1 Methicillin-resistente Staphylococcus aureus (MRSA) ................................... 18 2.7 Handschuhe .............................................................................................................. 21 2.7.1 Nutzen und Limitationen von Handschuhen ...................................................... 21 3 Veröffentlichung ............................................................................................................... 24 3.1 Eigenanteil zur Veröffentlichung ................................................................................ 24 3.1.1 Publikation ......................................................................................................... 26 4 Diskussion ........................................................................................................................ 50 5 Zusammenfassung ........................................................................................................... 61 6 Summary .......................................................................................................................... 63 7 Literaturverzeichnis .......................................................................................................... 65 Danksagung .............................................................................................................................. 7

Surgical hand preparation in an equine hospital: Comparison of general practice with a standardised protocol and characterisation of the methicillin-resistant Staphylococcus aureus recovered

Presurgical hand asepsis is part of the daily routine in veterinary medicine. Nevertheless, basic knowledge seems to be low, even among specialised veterinary surgeons. The major objectives of our study were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary hospital and their effectiveness in reducing bacteria from hands in comparison to a standardised protocol (phase 2). Assessment of individual habits focused on time for hand washing and disinfection, the amount of disinfectant used, and the usage of brushes. The standardised protocol defined hand washing for 1 min with liquid neutral soap without brushing and disinfection for 3 min. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium®. Total bacterial counts were determined before and after hand washing, after disinfection, and after surgery. Hands were immersed in 100 ml sterile sampling fluid for 1 min and samples were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Glove perforation test was carried out at the end of the surgical procedure. Differences in the reduction of relative bacterial numbers between current habits and the standardised protocol were investigated using Mann-Whitney-Test. The relative increase in bacterial numbers as a function of operation time (≤60 min, >60 min) and glove perforation as well as the interaction of both was investigated by using ANOVA. Forty-six and 41 preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly with regard to time (up to 8 min) and amount of disinfectant (up to 48 ml) used both between participants and between various applications of a respective participant. Comparison of current habits and the standardised protocol revealed that the duration of hand washing had no significant effect on reducing bacteria. Contrary, the reduction in bacterial numbers after disinfection by the standardised protocol was significantly higher (p<0.001) compared to routine every-day practice. With regard to disinfection efficacy, the standardised protocol completely eliminated individual effects. The mean reduction in phase 1 was 90.72% (LR = 3.23; right hand) and 89.97% (LR = 3.28; left hand) compared to 98.85% (LR = 3.29; right hand) and 98.92% (LR = 3.47; left hand) in phase 2. Eight participants (19%) carried MRSA (spa type t011, CC398) which is well established as a nosocomial pathogen in veterinary clinics. The isolates could further be assigned to a subpopulation which is particularly associated with equine clinics (mainly t011, ST398, gentamicin-resistant). Glove perforation occurred in 54% (surgeons) and 17% (assistants) of gloves, respectively, with a higher number in long-term invasive procedures. Overall, bacterial numbers on hands mainly increased over time, especially when glove perforation occurred. This was most distinct for glove perforations on the left hand and with longer operating times. Our results demonstrate that standardised protocols highly improve the efficacy of hand asepsis measures. Hence, guiding standardised protocols should be prerequisite to ensure state-of-the-art techniques which is essential for a successful infection control intervention.Peer Reviewe

Surgical hand preparation in an equine hospital: Comparison of general practice with a standardised protocol and characterisation of the methicillin-resistant Staphylococcus aureus recovered

Presurgical hand asepsis is part of the daily routine in veterinary medicine. Nevertheless, basic knowledge seems to be low, even among specialised veterinary surgeons. The major objectives of our study were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary hospital and their effectiveness in reducing bacteria from hands in comparison to a standardised protocol (phase 2). Assessment of individual habits focused on time for hand washing and disinfection, the amount of disinfectant used, and the usage of brushes. The standardised protocol defined hand washing for 1 min with liquid neutral soap without brushing and disinfection for 3 min. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium®. Total bacterial counts were determined before and after hand washing, after disinfection, and after surgery. Hands were immersed in 100 ml sterile sampling fluid for 1 min and samples were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Glove perforation test was carried out at the end of the surgical procedure. Differences in the reduction of relative bacterial numbers between current habits and the standardised protocol were investigated using Mann-Whitney-Test. The relative increase in bacterial numbers as a function of operation time (≤60 min, >60 min) and glove perforation as well as the interaction of both was investigated by using ANOVA. Forty-six and 41 preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly with regard to time (up to 8 min) and amount of disinfectant (up to 48 ml) used both between participants and between various applications of a respective participant. Comparison of current habits and the standardised protocol revealed that the duration of hand washing had no significant effect on reducing bacteria. Contrary, the reduction in bacterial numbers after disinfection by the standardised protocol was significantly higher (p<0.001) compared to routine every-day practice. With regard to disinfection efficacy, the standardised protocol completely eliminated individual effects. The mean reduction in phase 1 was 90.72% (LR = 3.23; right hand) and 89.97% (LR = 3.28; left hand) compared to 98.85% (LR = 3.29; right hand) and 98.92% (LR = 3.47; left hand) in phase 2. Eight participants (19%) carried MRSA (spa type t011, CC398) which is well established as a nosocomial pathogen in veterinary clinics. The isolates could further be assigned to a subpopulation which is particularly associated with equine clinics (mainly t011, ST398, gentamicin-resistant). Glove perforation occurred in 54% (surgeons) and 17% (assistants) of gloves, respectively, with a higher number in long-term invasive procedures. Overall, bacterial numbers on hands mainly increased over time, especially when glove perforation occurred. This was most distinct for glove perforations on the left hand and with longer operating times. Our results demonstrate that standardised protocols highly improve the efficacy of hand asepsis measures. Hence, guiding standardised protocols should be prerequisite to ensure state-of-the-art techniques which is essential for a successful infection control intervention

Surgical hand preparation in an equine hospital: Comparison of general practice with a standardised protocol and characterisation of the methicillin-resistant Staphylococcus aureus recovered

Presurgical hand asepsis is part of the daily routine in veterinary medicine. Nevertheless, basic knowledge seems to be low, even among specialised veterinary surgeons. The major objectives of our study were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary hospital and their effectiveness in reducing bacteria from hands in comparison to a standardised protocol (phase 2). Assessment of individual habits focused on time for hand washing and disinfection, the amount of disinfectant used, and the usage of brushes. The standardised protocol defined hand washing for 1 min with liquid neutral soap without brushing and disinfection for 3 min. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium®. Total bacterial counts were determined before and after hand washing, after disinfection, and after surgery. Hands were immersed in 100 ml sterile sampling fluid for 1 min and samples were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Glove perforation test was carried out at the end of the surgical procedure. Differences in the reduction of relative bacterial numbers between current habits and the standardised protocol were investigated using Mann-Whitney-Test. The relative increase in bacterial numbers as a function of operation time (≤60 min, >60 min) and glove perforation as well as the interaction of both was investigated by using ANOVA. Forty-six and 41 preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly with regard to time (up to 8 min) and amount of disinfectant (up to 48 ml) used both between participants and between various applications of a respective participant. Comparison of current habits and the standardised protocol revealed that the duration of hand washing had no significant effect on reducing bacteria. Contrary, the reduction in bacterial numbers after disinfection by the standardised protocol was significantly higher (p<0.001) compared to routine every-day practice. With regard to disinfection efficacy, the standardised protocol completely eliminated individual effects. The mean reduction in phase 1 was 90.72% (LR = 3.23; right hand) and 89.97% (LR = 3.28; left hand) compared to 98.85% (LR = 3.29; right hand) and 98.92% (LR = 3.47; left hand) in phase 2. Eight participants (19%) carried MRSA (spa type t011, CC398) which is well established as a nosocomial pathogen in veterinary clinics. The isolates could further be assigned to a subpopulation which is particularly associated with equine clinics (mainly t011, ST398, gentamicin-resistant). Glove perforation occurred in 54% (surgeons) and 17% (assistants) of gloves, respectively, with a higher number in long-term invasive procedures. Overall, bacterial numbers on hands mainly increased over time, especially when glove perforation occurred. This was most distinct for glove perforations on the left hand and with longer operating times. Our results demonstrate that standardised protocols highly improve the efficacy of hand asepsis measures. Hence, guiding standardised protocols should be prerequisite to ensure state-of-the-art techniques which is essential for a successful infection control intervention

Surgical hand preparation in an equine hospital: Comparison of general practice with a standardised protocol and characterisation of the methicillin-resistant Staphylococcus aureus recovered

Presurgical hand asepsis is part of the daily routine in veterinary medicine. Nevertheless, basic knowledge seems to be low, even among specialised veterinary surgeons. The major objectives of our study were to assess current habits for presurgical hand preparation (phase 1) among personnel in a veterinary hospital and their effectiveness in reducing bacteria from hands in comparison to a standardised protocol (phase 2). Assessment of individual habits focused on time for hand washing and disinfection, the amount of disinfectant used, and the usage of brushes. The standardised protocol defined hand washing for 1 min with liquid neutral soap without brushing and disinfection for 3 min. All participants (2 surgeons, 8 clinic members, 32 students) used Sterillium®. Total bacterial counts were determined before and after hand washing, after disinfection, and after surgery. Hands were immersed in 100 ml sterile sampling fluid for 1 min and samples were inoculated onto Columbia sheep blood agar using the spread-plate method. Bacterial colonies were manually counted. Glove perforation test was carried out at the end of the surgical procedure. Differences in the reduction of relative bacterial numbers between current habits and the standardised protocol were investigated using Mann-Whitney-Test. The relative increase in bacterial numbers as a function of operation time (≤60 min, >60 min) and glove perforation as well as the interaction of both was investigated by using ANOVA. Forty-six and 41 preparations were carried out during phase 1 and phase 2, respectively. Individual habits differed distinctly with regard to time (up to 8 min) and amount of disinfectant (up to 48 ml) used both between participants and between various applications of a respective participant. Comparison of current habits and the standardised protocol revealed that the duration of hand washing had no significant effect on reducing bacteria. Contrary, the reduction in bacterial numbers after disinfection by the standardised protocol was significantly higher (p<0.001) compared to routine every-day practice. With regard to disinfection efficacy, the standardised protocol completely eliminated individual effects. The mean reduction in phase 1 was 90.72% (LR = 3.23; right hand) and 89.97% (LR = 3.28; left hand) compared to 98.85% (LR = 3.29; right hand) and 98.92% (LR = 3.47; left hand) in phase 2. Eight participants (19%) carried MRSA (spa type t011, CC398) which is well established as a nosocomial pathogen in veterinary clinics. The isolates could further be assigned to a subpopulation which is particularly associated with equine clinics (mainly t011, ST398, gentamicin-resistant). Glove perforation occurred in 54% (surgeons) and 17% (assistants) of gloves, respectively, with a higher number in long-term invasive procedures. Overall, bacterial numbers on hands mainly increased over time, especially when glove perforation occurred. This was most distinct for glove perforations on the left hand and with longer operating times. Our results demonstrate that standardised protocols highly improve the efficacy of hand asepsis measures. Hence, guiding standardised protocols should be prerequisite to ensure state-of-the-art techniques which is essential for a successful infection control intervention