description of a triclosan-resistant bacterial enzyme has raised the question of whether resistance to this agent may develop more readily than to other antiseptic agents ( 218 ). In addi- tion, exposing Pseudomonas strains containing the MexAB- OprM efflux system to triclosan may select for mutants that are resistant to multiple antibiotics, including fluoroquinolones ( 230 ). Further studies are needed to determine whether reduced susceptibility to antiseptic agents is of epidemiologic significance and whether resistance to antiseptics has any influence on the prevalence of antibiotic-resistant strains ( 227 ). Surgical Hand Antisepsis Since the late 1800s, when Lister promoted the application of carbolic acid to the hands of surgeons before procedures, preoperative cleansing of hands and forearms with an antisep- tic agent has been an accepted practice ( 231 ). Although no randomized, controlled trials have been conducted to indi- cate that surgical-site infection rates are substantially lower when preoperative scrubbing is performed with an antiseptic agent rather than a non-antimicrobial soap, certain other fac- tors provide a strong rationale for this practice. Bacteria on the hands of surgeons can cause wound infections if intro- duced into the operative field during surgery ( 232 ); rapid multiplication of bacteria occurs under surgical gloves if hands are washed with a non-antimicrobial soap. However, bacterial growth is slowed after preoperative scrubbing with an antisep- tic agent ( 14,233 ). Reducing resident skin flora on the hands of the surgical team for the duration of a procedure reduces the risk of bacteria being released into the surgical field if gloves become punctured or torn during surgery ( 1,156,169 ). Finally, at least one outbreak of surgical-site infections occurred when surgeons who normally used an antiseptic surgical scrub prepa- ration began using a non-antimicrobial product ( 234 ). Antiseptic preparations intended for use as surgical hand scrubs are evaluated for their ability to reduce the number of bacteria released from hands at different times, including 1) immediately after scrubbing, 2) after wearing surgical gloves for 6 hours (i.e., persistent activity), and 3) after multiple applications over 5 days (i.e., cumulative activity). Immediate and persistent activity are considered the most important in determining the efficacy of the product. U.S. guidelines rec- ommend that agents used for surgical hand scrubs should sub- stantially reduce microorganisms on intact skin, contain a nonirritating antimicrobial preparation, have broad-spectrum activity, and be fast-acting and persistent ( 19,235 ). Studies have demonstrated that formulations containing 60%–95% alcohol alone or 50%–95% when combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate, lower bacterial counts on the skin immediately postscrub more effectively than do other agents (Table 4). The next most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap ( 104,119,186,188, 203,204,206,208,236 ). Because studies of PCMX as a surgi-
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