DETECTION, TREATMENT, AND BIOCONTAINMENT OF INFECTIOUS DISEASES 3. Resistance


A new and more worrying aspect supporting the reduced use of medicated soaps is the emergence of increased acquired resistance towards antisep- tics.20,21 In particular, the prevalence of Staphylo- coccus aureus carrying the chlorhexidine resistance gene qacA/B has been shown to increase in the hos- pital environment.22 This is a concern not just be- cause of resistance to chlorhexidine, but also because chlorhexidine resistance can potentially co- select for resistance to clinically-relevant antibiot- ics. The overuse of CHX scrubbing soaps, which results in the spreading of large quantities of diluted active substance that is more likely to be bacterio- static than bactericidal, could be a contributing fac- tor in antibiotic resistance among pathogens on the hands or in the environment. Due to the fast kill- ing activity of alcohol and the lack of any known (or plausible) genetic mechanisms that would allow for transmission of inherent alcohol resistance, ac- quired resistance to AHRs has not been shown to date, nor is it likely to be encountered, providing another major reason to move towards these products.


4. Outside Surgery


Outside the closed environment of the surgery the- ater, the hands of healthcare workers are thought to play a crucial role in the occurrence of SSI and other HAIs. Hand hygiene is therefore regarded as one of the most effective measures to prevent HAIs. Several reports have shown a temporal association between interventions to improve hand hygiene measures or compliance rates and reduced infection rates. A recent British report evaluating the “Clean your hands” campaign showed that in the 4-year study period, the AHR use per bed day raised more than a twofold simultaneously with a twofold decrease in MRSA (methicillin resistant Staphylo- coccus aureus) bacteremia and Clostridium difficile infections,23 strongly emphasizing the importance of these measures. While studies on the impact of hand hygiene on


HAIs are often done as part of multi-modal inter- ventions and the specific role of hand hygiene im- provements can be difficult to discern, it is widely accepted that hand hygiene compliance is a key com- ponent of infection prevention and an indicator of patient care. While there are clear differences be- tween equine and human healthcare, there is no reason to think that the impact of hand hygiene in equine medicine and surgery would be any less than in human medicine. This, combined with evidence of deficiencies in hand hygiene in equine medicine, indicates a need for improvement. Compliance with hand hygiene measures should be improved. The weakest link is typically compliance by clini- cians, as the practices of nursing staff are often superior.24,25 Increasing the ease of performing hand hygiene is likely a critical factor and the intro- duction of AHRs and improving the accessibility of


materials has been an important factor to increase hand hygiene compliance rates.26 New technolo- gies are underway to electronically monitor the com- pliance in human healthcare, with financial incentives for health care staff. Ultimately, how- ever, increased awareness and personal responsibil- ity by all personnel is critical for improving hand hygiene rates.


5. Skin Health


It is clear that the veterinary occupation also has a real impact on the health of our skin. Not only are human medical staff known to acquire more a pathogenic resident microbiota over time,27 a high proportion of healthcare workers develop occupa- tional dermatitis, mostly related to repeated washing with chlorhexidine soaps.28,29 However, one of the most important determinants of health- care workers’ resistance to change to AHRs is the unfounded belief that AHRs are more harmful to their skin than soap and water.30,31 In reality, each hand wash detrimentally alters the lipid layer of the superficial skin, creating the loss of protective agents such as amino acids and natural antimicrobial factors. Prolonged and repeated washing leads to a damaged barrier function of the stratum corneum, resulting in the skin becoming more permeable for toxic agents and bacteria. On the contrary, AHR solutions have been shown to have less detrimental effects on skin than soaps in both human healthcare32 and veterinary set- tings.10 This corroborates the results from the aforementioned survey4 that identified surgeons using antimicrobial soaps as pre-surgical hand preparation methods as having lower overall hand health scores compared to those using AHRs. This was particularly true for skin moisture con- tent, with surgeons using antimicrobial soaps re- porting significantly dryer hands than those using AHR solutions (Table 1). This is mainly due to the absence of the aforementioned deleterious ef- fects of soap washing combined with the fact that AHR products contain humectants and need shorter application times.30 Furthermore, al- though lipid layers are also dissolved with AHRs, they are not washed away but rather reincorpo- rated by the action of rubbing and emollients that are included in virtually all AHR products can facilitate restoration of a normal barrier. As mentioned before, unnecessary washing should be avoided, particularly with hot water.28


6. Compliance Issues


In our latest survey,4 89 respondents stated they believe AHRs are superior to traditional hand scrub- bing techniques for obtaining hand asepsis. Never- theless, over 42% of these respondents report the use of antimicrobial soaps in their protocol, clearly indicating a lack of compliance with their own be- liefs. Reasons for this have not been specifically evaluated, but it may be rooted in the fact that many


AAEP PROCEEDINGS  Vol. 60  2014 221


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