Surgical hand rubbing compared with surgical
hand scrubbing: comparison of efficacy and costs
M.P. Tavolaccia,*, I. Pitroua, V. Merlea, S. Haghighatb,
D. Thillarda, P. Czernichowa
aDepartment of Epidemiology and Public Health, Rouen University Hospital, Rouen, France
bDepartment of Pharmacy, Rouen University Hospital, Rouen, France
Received 4 July 2005; accepted 22 November 2005
Available online 3 March 2006
Surgical hand rubbing;
rub; Surgical hand
hand rubbing (SHR) with the efficacy of surgical hand scrubbing (SHS),
and to determine the costs of both techniques for surgical hand disinfec-
tion. A review of studies reported in the literature that compared the ef-
ficacy of SHS and SHR was performed using MEDLINE. The costs of SHR
and SHS were estimated based on standard hospital costs. The literature
showed that SHR had immediate efficacy that was similar to that of SHS,
but SHR had a more lasting effect. SHR reduced costs by 67%. In conclusion,
SHR is a cost-effective alternative to SHS.
ª 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights
The aim of this study was to compare the efficacy of surgical
The aim of surgical hand disinfection is the
elimination of transient and the reduction of
resident micro-organisms. This process is required
for all surgical procedures and for some invasive
medical procedures to prevent serious infections
associated with mortality, morbidity and high
Hand rubbing with alcohol-based hand rub (AHR)
is recommended instead of handwashing with un-
medicated soap or antiseptic soap6based on sev-
eral studies that have shown better compliance7e9
and dermal tolerance.10,11For surgical hand disin-
fection, the use of antiseptic soap is the traditional
technique. European recommendations for surgical
hand disinfection conclude that ‘there is no crite-
rion to decide when surgical hand scrubbing is pre-
ferred as opposed to surgical hand rubbing’.12
According to the French Society for Hospital
gical hand scrubbing’.13In France, agents that have
passed prEN 12054 (suspension tests) and prEN
12791 (in vivo test) are available for use.14
* Corresponding author. Address: De ´partement d’Epide ´miolo-
gie et de Sante ´ Publique, CHU-Ho ˆpitaux de Rouen, 1, rue de
Germont, 76031 Rouen Cedex, France. Tel.: þ33 2 32 88 88
82; fax: þ33 2 32 88 86 37.
E-mail address: Marie-Pierre.Tavolacci@chu-rouen.fr
0195-6701/$ - see front matter ª 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection (2006) 63, 55e59
However, studies have reported that lack of confi-
dence about the efficacy of AHR is the main reason
given for not adhering to hand rubbing.15,16Confir-
mation of the efficacy of SHR compared with SHS
may convince healthcare workers (HCWs) to use
this technique. Cost could be another reason for
non-use of AHR.
of SHR and SHS, and to determine the costs of both
techniques for surgical hand disinfection.
A review of published studies comparing the
efficacy of surgical hand scrubbing (SHS) and
surgical hand rubbing (SHR) was performed using
PubMed and MEDLINE databases from 1992 to
March 2005 by combining the following keywords:
surgical hand disinfection and alcohol hand rubs,
alcohol-based hand rub, or n-propanol or isopro-
panol, surgical hand rub, surgical hand scrub and
surgical hand rubbing. The original articles com-
pared the efficacy of SHS and SHR in practical
conditions. Articles written in French or English
were included, and articles regarding antiseptic
disinfection were excluded.
The standard costs of surgical hand disinfection
(SHR and SHS) were based on the hospital cost. The
different products used for both techniques were
established according to the recommendations for
surgical hand disinfection of the French Society for
Hospital Hygiene and the European recommenda-
tions as follows.12
SHS requires soaping hands and forearms for
1 min each side with antiseptic solution, brushing
nails for 1 min, and rinsing with bacteriologically
controlled water, sometimes using a filter depend-
ing on water quality, before soaping hands and
forearms once again, then rinsing and drying
them with sheets of sterile paper towel.17Ten
millilitres of 4% chlorhexidine gluconate (Hibis-
crub, Regent Medical, Levallois Perret, France) or
6 mL of 4% povidone iodine (Betadine, Viatris,
Merignac, France) is required. Antiseptic soap is
used in the authors’ setting.
Before beginning SHR, if the hands are visibly
soiled, a simple wash with an unmedicated soap
(4 mL) is performed, nails are cleaned with a brush,
wiping with non-sterile paper. The user is then re-
quested to perform SHR with an AHR that cover
hands and forearms as well as the elbows (4.5 mL
for each side) and to continue rubbing until the
ond AHR application excluding the elbows (4.5 mL)
(a total of 13.5 mL of AHR). The AHRs used were
Sterillium Gel (ethanol) (Rivadis Laboratories,
Thouard, France) and Manurub (phenoxyethanol,
n-propanol, ethanol) (Anios Laboratories, Lille,
France). AHR is used in the authors’ setting.
The costs (tax exempt) of the various products
were supplied by the economic department and
the pharmacy of Rouen University Hospital, and the
costs of sterile paper towels and water filters were
also identified (Table I). Use of water filters de-
pends on water quality, so the cost was calculated
with or without filters. Simple washing before SHR
is only necessary if hands are visibly soiled, so the
cost of SHR was calculated with and without inclu-
sion of the cost of simple handwashing.
Six efficacy studies met the selection criteria. The
criteria of efficacy used were bactericidal activity
(quantitative colony counts with glove juice tech-
nique and fingertip impression) or the rate of
surgical site infection (SSI) in accordance with
the Centers for Disease Control and Prevention
definitions for nosocomial infections.18,19
results of these studies are given in Table II.20e26
Efficacy appears to be equivalent or superior for
The costs of SHS and SHR are given for each
product in Table III. The global cost of each tech-
nique, taking into account whether or not simple
washing was performed before SHR and the use
or non-use of a water filter with SHS, is shown in
Figure 1. The cost of a filter for each SHS
surgical hand scrubbing and surgical hand rubbing
(in Euros, 2005)
Cost of the different products required for
ProductsCost (V, tax exempt)
Hibiscrub (500 mL)
Betadine scrub (500 mL)
Sterile towel (two sheets)
Antibacterial water filters
Pall Aquasafe ‘7 jours’
Aniosoft (1 L)
Non-sterile towel (98 sheets)
Alcohol-based hand rubs
Manurub (500 mL)
Sterillium Gel (475 mL)
56 M.P. Tavolacci et al.
Methods and results of the six published studies on the efficacy of surgical hand scrubbing (SHS) and surgical hand rubbing (SHR)
Hobson et al.20
MethodsSHSSHR Criteria of efficacy
Time of measureResults
90 healthy volunteers Betadine or HibiclensTrispetin
(total time of 3 min)
61% ethyl alcohol, 1%
chlorhexidine, 3)2 mL
Manorapid, 3)5 mL;
total time of 3 min
(prior to the first
procedure: wash with
1 min, 3 h and 6 h
Pre and post
15 pre and post
SHR>SHS to 1 min,
3 h and 6 h
Larson et al.21
20 healthy volunteersChlorhexidine 4% Bactericidal activitya
Bryce et al.22
Observation Betadine or Hibiscrub
Operation< 2 h:
Operation> 3 h:
trial; 60 volunteers
Before and after
1 min, 3 h and 6 h
3 h after
SHR>SHS to 1 min,
3 h and 6 h
soap¼ n-propanol 60%
2.44% (SHR) vs 2.48%
(SHS) (P<0.01; test
Mulberry et al.25
20 healthy volunteers
Chlorhexidine 4% 1% chlorhexidine/
alcohol, 3)2 mL
Softa Man, Sterillium,
(total time of 3 min)
Marchetti et al.24
Derman plus, Hibiscrub,
Parienti et al.26
trial; 2252 SHR and
Betadine or HibiscrubSterillium, twice 5 mL
(twice 2 min 30) (prior
to the first procedure:
wash with unmedicated
Rate of surgical
Betadine: povidone iodine 4%.
Derman Plus: 1% triclosan.
Hibiscrub, Hibiclens: chlorhexidine 4%.
Triseptin: 70% ethanol.
Manorapid: 54% ethanol, 10% 1-propanol.
Softa Man: 45% ethanol, 18% 1-propanol.
Sterilium: 45% 2-propanol, 30% 1-propanol, 0.2% mecetronium etilsulphate.
aBactericidal activity: quantitative colony counts with fingertip impression cultures and/or glove juice culture.18
Surgical hand rubbing vs surgical hand scrubbing
procedure was assessed and the result of the sen-
sitivity analysis with a single-use filter is shown in
Figure 2. The cost only varied slightly beyond 35
SHS procedures per day.
This literature review indicated that SHR has an
immediate bactericidal efficacy, similar to that of
SHS, but with a more lasting effect. SHR was
equivalent to SHS in preventing SSI after clean
and clean-contaminated surgery. SHR was found
to reduce the cost of hand disinfection by 67%.
The sensitivity analysis showed that the cost of
SHS is only slightly modified beyond 35 SHS pro-
cedures per day and per water tap. The cost of
SHR can also be lower for short and repeated
operations, where washing with unmedicated
soap is not always necessary, or for invasive
procedures requiring surgical hand disinfection if
hands are not visibly soiled.12,13The savings gen-
erated using SHR are not restricted to the cost of
the procedure. The cost of HCWs’ time was not
estimated but SHR saves 1e2 min (SHS takes
5 min whereas SHR generally takes 3 min).13Sim-
ilarly, the use of SHR for surgical hand disinfec-
tion avoids the need for bacteriological control
of water or use of a filter. The cost savings gener-
ated by reducing water samples can therefore
add to the overall economy.
In conclusion, the use of SHR should be consid-
ered by HCWs as an attractive alternative to SHR,
with a similar efficacy and a lower cost. SHR is also
a cost-effective alternative to SHS outside the
operating theatre (i.e. intensive care units, inter-
ventional radiology) where water is not systemat-
ically bacteriologically controlled and could be
a source of nosocomial infection.27,28This ap-
proach could contribute to improved quality of
soap and use of a water filter. SG, Sterilium Gel; SW, simple washing with unmedicated soap; M, Manurub; B, Betadine;
Global cost of a surgical disinfection according to the techniques, products and washing with unmedicated
Cost of surgical hand scrubbing and surgical hand rubbing (in Euros, tax exempt)
ProductsSurgical hand rubbing
(V, tax free)
Surgical hand scrubbing (V, tax exempt)
Alcohol-based hand rubs
or antiseptic soap
1.045Total (V) 0.366 0.386
58M.P. Tavolacci et al.
surgical hand decontamination outside the operat- Download full-text
The authors thank Richard Medeiros, Rouen Uni-
versity Hospital Medical Editor, for valuable advice
in editing the manuscript.
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Sensitivity analysis of surgical hand scrubbing
Surgical hand rubbing vs surgical hand scrubbing59