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Microbiologic effects of emollient on gloved hands
E. L. Larson, R.N., Ph.D., F.A.A.N. M. P. Wilder B. E. Laughon, Ph.D. Baltimore,
Maryland,
and Blacksburg,
Virginia
Health care personnel whose work necessitates frequent and/or prolonged washing of the hands with antiseptics often complain of skin drying or irritation.’ Such irritation is undesirable, not only because it causes discomfort, but also because it can increase the risk of skin colonization with gram-negative bacteria or other potential pathogens from the hospital environment .2f3 Meers and Yeo4 found that handwashing with plain soap containing no antimicrobial ingredients was associated with increased shedding of skin squamous cells that carried viable bacteria. This resulted in an actual increase in numbers of colony-forming units (CFU) shed into the environment. When an antimicrobial soap was used, these increased counts did not result. Further, Wilson et al5 recently reported that the combination of washing with an antimicrobial-containing soap (chlorhexidine gluconate) followed by application of an emollient on the skin of the chest resulted in a reduction in bacterial counts that was even greater than that after washing alone. However, the composition of the skin flora was altered, with recovery of yeast being more frequent in the soap and emollient group.
From the Johns Hopkins University School of Nursing, Baltimore, and Virginia Polytechnic Institute and State University, Blacksburg. Supported in part by Calgon Corporation, St. Louis, MO Reprint requests: E. L. Larson, R.N., Ph.D., F.A.A.N., Nutting Chair in Clinical Nursing, The Johns Hopkins University School of Nursing, Baltimore, MO 21205.
In our institution, some nurses have begun to apply sterile petroleum jelly to their hands after scrubbing and before donning gloves for surgical procedures. The purpose of this study was to evaluate the quantitative and qualitative microbiologic effects of applying an emollient (petroleum jelly) to the skin of the hands after scrubbing with an antimicrobial-containing soap. MA Ten adult volunteers participated in the study on three separate occasions, at least 24 hours apart. Each subject performed a S-minute hand wash, using a standardized protocol and a povidone-iodine-impregnated disposable scrub brush-sponge (D&de, Inc., Ft. Worth, Tex.). Two and a half grams of individually packaged sterile petroleum jelly (Vaseline; Chesebrough-Ponds, Inc., Greenwich, Conn.) was then applied to one of the-subject’s randomly selected hands. It was rubbed onto all surfaces by an investigator wearing sterile gloves. The subject then wore sterile gloves on both hands (one with andone without Vaseline) for 15 minutes on the first testing day, 1 hour on the second day, and 4 hours on the third day. Microbiologic sampling of both hands of each subject was done twice on each of the three test days: immediately after the S-minute wash and immediately after removal of the gloves. A sterile bag technique6 was used to assay organisms on the hand. The subject inserted each hand into a sterile polyethylene bag containing 50 ml
Volume
15 Number
August
1987
4
Emollient on gloved hands
169
Table 1. Mean log CFU on hands with and without Vaseline Time in gloves Baseline’ (b8fom glovlng) Aerobss With Without
Vaseline Vaseline
Anaerobes
15 mln’ Awobes
6.64 (21.29)
6.03 (5.71)
6.85 (k-1.28)
6.88 (?1.73)
6.02 (k1.17)
6.49 (k1.47)
Values are expressed as mean ( f SD). ‘Wilcoxon matched-pairs signed-rank test between
Vaseline
1 hr’
AMWOb@S
(f
5.99 (k1.28)
and no-Vaseline
of sampling solution (sterile distilled water containing per liter: lecithin, 20 gm; tryptone, 1 gm; Tween 80, 50 ml; sodium thiosulfate, 6 gm; sodium oleate, 6 gm; protease peptone, 1 gm; pH, 7.2 to 7.4). In preliminary studies, we determined that there was no significant increase or decrease in CFU in the solution within the first 2 hours after sampling. The entire hand surface was rubbed vigorously through the wall of the bag for 1 minute. All specimens were processed within 1 hour of sampling. A 0.1 ml volume of serial dilutions up to lo-’ was placed on the following nutrient media: trypticase soy agar containing yeast extract, 5 gm/L, and Tween 80,l ml/L (general nutrient medium); prereduced brain-heart infusion agar (Baltimore Biologic Laboratories, Cockeysville, Md.) containing 7% sheep’s blood and yeast extract, 5 gm/L, for anaerobic incubation; MacConkey agar (Baltimore Biologic Laboratories) for isolation of gram-negative bacteria; and Sabouraud dextrose agar containing 0.005% chloramphenicol for selective isolation of yeast. Plates were incubated at 37” C aerobically for 48 hours, anaerobically for 4 days, and on Sabouraud for 5 days. The microbial yield from the entire hand was calculated. Microbial counts are reported in logarithms (base 10). The Wilcoxon matched-pairs signedrank test was used to compare differences in log CFU counts at baseline between the right and left hands, and differences between log CFU at baseline and each of the three time periods (15 minutes, 1 hour, and 4 hours after gloving) between the hand with and without Vaseline.
6.50 .99)
hands,
Aerobes 6.64 ( 5 1.40) 7.10 (k1.66)
4 hr’ Anaerobes 6.72 (2.94) 6.35 (21.09)
Awobes 7.08 (21.28) 7.44 (k1.46)
Anaerobes 6.47 (k.85) 6.64 (-tl.OO)
all p > 0.25.
ReSULTS
The mean log CFU counts at baseline (immediately after the S-minute wash) were 6.56 (2 1.53) for the right hand and 6.99 ( + 1.57) for the left hand. Although these differences were not statistically significant (p > O.lO), the left hand had higher microbial counts on 20 occasions whereas the right hand had higher counts on 10 occasions. Mean aerobic and anaerobic log CFU on hands with and without Vaseline were not significantly different after 15 minutes, 1 hour, or 4 hours of wearing surgical gloves (Table 1). However, there were large individual variations within the group. Changes in aerobic log CFU from baseline to after 4 hours of gloving ranging from - 2.75 to + 3.56 log for individual subjects. On the no-Vaseline hand after 15 minutes, six subjects had increased aerobic counts and four had decreased counts; after 1 hour and 4 hours, seven had the same or increased and three had decreased counts. On the Vaselinecovered hand, five subjects had increased and five had decreased, aerobic counts by 4 hours (Table 2). Similarly for anaerobes, by 4 hours of gloving all but one individual in the Vaseline and the no-Vaseline groups had increased counts, but there were no significant differences between the groups. From neither Vaseline or no-Vaseline hands was yeast recovered. Recovery of gram-negative bacteria was possible in 8/30 (26.7%) of baseline samples, 9/30 (30%) of the Vaseline hands and 7/30 (23.3%) of the no-Vaseline hands after gloving.
American
170
Larson et al.
Table
2. Differences
INFECTION
in aerobic
Journal
of
CONTROL.
log CFU on hands from baseline Time In gloves
15 min VESOIIIW
4 hr
1 hr No Vaseline
VSSMM,
ViWBiillS
No Vaseline
0
+0.62 -2.29 +0.09 -0.19 -1.61
tQ.13 iO.65 +0.36 +0.79 -0.07
I- 3.00 +0.49 -2.85
-2.75 -1 12 i-3.56
1 2 3 4 5 6
+0.12
+ 0.04
+ 0.27
-0.30 +0.14 +2.22 +0.12 - 0.39
+0.08 +0.13 - 1.97 +0.14 -1.48
+2.42 -1.10 -2.93 -2.67 -0.43
1-1.66 -0.27 +I07 +3.19 +2.48
7 8 9
+1.30 +0.69
-2.25 +0.37
+2.89 +0.24
+4.68 + 0.06
10
Mean (*SD)
+0.05 + 1.67 +0.56 (20.88)
-1.80 +2.47 -0.44 (k-1.44)
+ 0.92 +0.15 -0.02 (21.89)
In at least two previous studies7n8 slightly, but no statistically significantly, higher bacterial counts have been reported on subjects’ left as compared with the right hands. Our findings corroborate this, indicating that, although the right and left hands might be used in paired tests, slight differences in counts should be anticipated, with the left hand more likely to have higher counts. In addition a large day-to-day variability in individual microbial counts has been previously reported and is usually the major source of variation in tests such as these.‘, ’ Because of this variability, it is advisable to perform statistical tests (as we did), on differences in log counts from individual baseline measurements, rather than on the actual log counts, and to establish a baseline for each testing period, This wide individual variability also suggests that reporting only mean changes in counts for an entire group may be misleading and result in inappropriate conclusions. There was a general, although not significant, trend in this study toward increasing bacterial counts with increased gloving time, whether or not Vaseline was applied. This is consistent with other studies’oY’s and is attributed to the fact that povidune-iodine has some persistence or residuai activity on the skin. Other products such as hexachlorophene and chlorhexidine gluconate bind to the stratum corneum much
-
No vaeeline
-0.17 -2.95 + 0.97 (k2.14)
-0.26 +3.15 t 0.01 (e1.98)
-267
-+ 0.36 +0.46
(+ 1.76)
more effectively so that the chemical remains active on the skin.‘6 Rotter et al.ls reported that treatment of hands with n-propanol resulted in a significantly greater reduction in flora after 3 hours of gloving than either povidone-iodine or chlorhexidine. It might be postulated that there would be a proliferation of flora when hands are covered with petroleum jelly. For one thing, it would seem that the petroleum jelly would cause an environment in which anaerobes would thrive. Second, organic material such as blood has been shown to interfere significantly with the activity of povidone-iodine.“! I3 Wilson et a1.,s however, found that disinfectantand lotiontreated skin had greater reductions in flora than control or disinfectant-treated skin alone. In this study, the absence of any sign&cant effect of Vaseline treatment on flora of the hands is somewhat surprising. However, it appears that petroleum jelly on the skin is rather benign. On the basis of our data, we conclude that the application of sterile petroleum jelly to the hands before gloving is probably safe and may reduce the drying effects of handwashing. We thank Maureen A. Stephens, need for this study.
R.N., fur suggesting
the
1. Larson E, Killen M. Factors influencing handwashing behavior of patient care personnel. AB&3 f#FECT CCINTROL 1982;10:93-9.
Volume 15 Number August 1987
4
Emollient on &wed hands
2. Larson E. Handwashing and skin: physiologic and bacteriologic aspects. Infect Control 1985;6:14-23. 3. Larson E, Leyden J, McGinley K, Grove G, Talbot G. Physiologic and microbiologic changes in skin related to frequent handwashing. Infect Control 1986;7:59-63. 4. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg 1978;81:99-105. 5. Wilson K, Ayers L, Stone K. The effects of chlorhexidine and an emollient on human microbial skin flora. Proceedings of Thirteenth Annual Educational Conference. Las Vegas: Association for Practitioners in Infection Control, 1986:lOO. 6. Larson EL, Strom MS, Evans CA. Analysis of three variables in sampling solutions used to assay bacteria of hands. J Clin Microbial 1980;12:355-60. 7. Spradlin CT. Bacterial abundance on hands and its implications for clinical trials of surgical scrubs. J Clin Microbial 1980;11:389-93. 8. Michaud RN, McGrath MB, Goss WA. Improved experimental model for measuring skin degerming activity on the human hand. Antimicrob Agents Chemother 1972;2:8-15. 9. Aly R, Maibach HI. Factors controlling skin bacterial
10.
11. 12.
Bound volumes available
13. 14. 15. 16.
17f
flora. In: Maibach H, Aly R, eds. Skin microbiology. New York: Springer-Verlag, 1981:29-39. Aly R, Maibach HI. Comparative evaluation of chlorhexidine gluconate (Hibiclens) and povidone-iodine (E-Z Scrub) sponge/brushes for presurgical hand scrubbing. Current Therapeutic Research 1983;34:740-5. Dineen P. An evaluation of the duration of the surgical scrub. Surg Gynecol Obstet 1969;126:1181-4. Eitzen HE, Ritter MA, Frence MLV, Gioe TJ. A microbiological in-use comparison of surgical hand-washing agents. J Bone Joint $urg 1979;61-A:403-6. Lowbury EJL, Lilly HA. The effect of blood on disinfection of surgeons hands. Br J Surg 1974;61: 19-2 1. Peterson AF, Rosenberg A, Alatary SD. Comparative evaluation of surgical scrub preparations. Surg Gyneco1 Obstet 1978;146:63-5. Rotter M, Koller W, Wewalka G. Povidone-iodine and chlorhexidine gluconate-containing detergents for disinfection of hands. J Hosp Infect 1980; 1: 149-58. Bruch M. Newer germicides: what they offer. In: Maibath H, Aly R, eds. Skin microbiology. New York: Springer-Verlag, 1981:103-12.
to subscribers
Bound volumes of AMERICAN JOURNAL OF INFECTION CONTROL are available to subscribers (only) for the 1987 issues from the Publisher, at a cost of $24.00 ($30.00 international) for Vol. 15 (January-December). Shipping charges are included. Each bound volume contains a subject and author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146 USA; phone 800-325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
Maryland,
and Blacksburg,
Virginia
Health care personnel whose work necessitates frequent and/or prolonged washing of the hands with antiseptics often complain of skin drying or irritation.’ Such irritation is undesirable, not only because it causes discomfort, but also because it can increase the risk of skin colonization with gram-negative bacteria or other potential pathogens from the hospital environment .2f3 Meers and Yeo4 found that handwashing with plain soap containing no antimicrobial ingredients was associated with increased shedding of skin squamous cells that carried viable bacteria. This resulted in an actual increase in numbers of colony-forming units (CFU) shed into the environment. When an antimicrobial soap was used, these increased counts did not result. Further, Wilson et al5 recently reported that the combination of washing with an antimicrobial-containing soap (chlorhexidine gluconate) followed by application of an emollient on the skin of the chest resulted in a reduction in bacterial counts that was even greater than that after washing alone. However, the composition of the skin flora was altered, with recovery of yeast being more frequent in the soap and emollient group.
From the Johns Hopkins University School of Nursing, Baltimore, and Virginia Polytechnic Institute and State University, Blacksburg. Supported in part by Calgon Corporation, St. Louis, MO Reprint requests: E. L. Larson, R.N., Ph.D., F.A.A.N., Nutting Chair in Clinical Nursing, The Johns Hopkins University School of Nursing, Baltimore, MO 21205.
In our institution, some nurses have begun to apply sterile petroleum jelly to their hands after scrubbing and before donning gloves for surgical procedures. The purpose of this study was to evaluate the quantitative and qualitative microbiologic effects of applying an emollient (petroleum jelly) to the skin of the hands after scrubbing with an antimicrobial-containing soap. MA Ten adult volunteers participated in the study on three separate occasions, at least 24 hours apart. Each subject performed a S-minute hand wash, using a standardized protocol and a povidone-iodine-impregnated disposable scrub brush-sponge (D&de, Inc., Ft. Worth, Tex.). Two and a half grams of individually packaged sterile petroleum jelly (Vaseline; Chesebrough-Ponds, Inc., Greenwich, Conn.) was then applied to one of the-subject’s randomly selected hands. It was rubbed onto all surfaces by an investigator wearing sterile gloves. The subject then wore sterile gloves on both hands (one with andone without Vaseline) for 15 minutes on the first testing day, 1 hour on the second day, and 4 hours on the third day. Microbiologic sampling of both hands of each subject was done twice on each of the three test days: immediately after the S-minute wash and immediately after removal of the gloves. A sterile bag technique6 was used to assay organisms on the hand. The subject inserted each hand into a sterile polyethylene bag containing 50 ml
Volume
15 Number
August
1987
4
Emollient on gloved hands
169
Table 1. Mean log CFU on hands with and without Vaseline Time in gloves Baseline’ (b8fom glovlng) Aerobss With Without
Vaseline Vaseline
Anaerobes
15 mln’ Awobes
6.64 (21.29)
6.03 (5.71)
6.85 (k-1.28)
6.88 (?1.73)
6.02 (k1.17)
6.49 (k1.47)
Values are expressed as mean ( f SD). ‘Wilcoxon matched-pairs signed-rank test between
Vaseline
1 hr’
AMWOb@S
(f
5.99 (k1.28)
and no-Vaseline
of sampling solution (sterile distilled water containing per liter: lecithin, 20 gm; tryptone, 1 gm; Tween 80, 50 ml; sodium thiosulfate, 6 gm; sodium oleate, 6 gm; protease peptone, 1 gm; pH, 7.2 to 7.4). In preliminary studies, we determined that there was no significant increase or decrease in CFU in the solution within the first 2 hours after sampling. The entire hand surface was rubbed vigorously through the wall of the bag for 1 minute. All specimens were processed within 1 hour of sampling. A 0.1 ml volume of serial dilutions up to lo-’ was placed on the following nutrient media: trypticase soy agar containing yeast extract, 5 gm/L, and Tween 80,l ml/L (general nutrient medium); prereduced brain-heart infusion agar (Baltimore Biologic Laboratories, Cockeysville, Md.) containing 7% sheep’s blood and yeast extract, 5 gm/L, for anaerobic incubation; MacConkey agar (Baltimore Biologic Laboratories) for isolation of gram-negative bacteria; and Sabouraud dextrose agar containing 0.005% chloramphenicol for selective isolation of yeast. Plates were incubated at 37” C aerobically for 48 hours, anaerobically for 4 days, and on Sabouraud for 5 days. The microbial yield from the entire hand was calculated. Microbial counts are reported in logarithms (base 10). The Wilcoxon matched-pairs signedrank test was used to compare differences in log CFU counts at baseline between the right and left hands, and differences between log CFU at baseline and each of the three time periods (15 minutes, 1 hour, and 4 hours after gloving) between the hand with and without Vaseline.
6.50 .99)
hands,
Aerobes 6.64 ( 5 1.40) 7.10 (k1.66)
4 hr’ Anaerobes 6.72 (2.94) 6.35 (21.09)
Awobes 7.08 (21.28) 7.44 (k1.46)
Anaerobes 6.47 (k.85) 6.64 (-tl.OO)
all p > 0.25.
ReSULTS
The mean log CFU counts at baseline (immediately after the S-minute wash) were 6.56 (2 1.53) for the right hand and 6.99 ( + 1.57) for the left hand. Although these differences were not statistically significant (p > O.lO), the left hand had higher microbial counts on 20 occasions whereas the right hand had higher counts on 10 occasions. Mean aerobic and anaerobic log CFU on hands with and without Vaseline were not significantly different after 15 minutes, 1 hour, or 4 hours of wearing surgical gloves (Table 1). However, there were large individual variations within the group. Changes in aerobic log CFU from baseline to after 4 hours of gloving ranging from - 2.75 to + 3.56 log for individual subjects. On the no-Vaseline hand after 15 minutes, six subjects had increased aerobic counts and four had decreased counts; after 1 hour and 4 hours, seven had the same or increased and three had decreased counts. On the Vaselinecovered hand, five subjects had increased and five had decreased, aerobic counts by 4 hours (Table 2). Similarly for anaerobes, by 4 hours of gloving all but one individual in the Vaseline and the no-Vaseline groups had increased counts, but there were no significant differences between the groups. From neither Vaseline or no-Vaseline hands was yeast recovered. Recovery of gram-negative bacteria was possible in 8/30 (26.7%) of baseline samples, 9/30 (30%) of the Vaseline hands and 7/30 (23.3%) of the no-Vaseline hands after gloving.
American
170
Larson et al.
Table
2. Differences
INFECTION
in aerobic
Journal
of
CONTROL.
log CFU on hands from baseline Time In gloves
15 min VESOIIIW
4 hr
1 hr No Vaseline
VSSMM,
ViWBiillS
No Vaseline
0
+0.62 -2.29 +0.09 -0.19 -1.61
tQ.13 iO.65 +0.36 +0.79 -0.07
I- 3.00 +0.49 -2.85
-2.75 -1 12 i-3.56
1 2 3 4 5 6
+0.12
+ 0.04
+ 0.27
-0.30 +0.14 +2.22 +0.12 - 0.39
+0.08 +0.13 - 1.97 +0.14 -1.48
+2.42 -1.10 -2.93 -2.67 -0.43
1-1.66 -0.27 +I07 +3.19 +2.48
7 8 9
+1.30 +0.69
-2.25 +0.37
+2.89 +0.24
+4.68 + 0.06
10
Mean (*SD)
+0.05 + 1.67 +0.56 (20.88)
-1.80 +2.47 -0.44 (k-1.44)
+ 0.92 +0.15 -0.02 (21.89)
In at least two previous studies7n8 slightly, but no statistically significantly, higher bacterial counts have been reported on subjects’ left as compared with the right hands. Our findings corroborate this, indicating that, although the right and left hands might be used in paired tests, slight differences in counts should be anticipated, with the left hand more likely to have higher counts. In addition a large day-to-day variability in individual microbial counts has been previously reported and is usually the major source of variation in tests such as these.‘, ’ Because of this variability, it is advisable to perform statistical tests (as we did), on differences in log counts from individual baseline measurements, rather than on the actual log counts, and to establish a baseline for each testing period, This wide individual variability also suggests that reporting only mean changes in counts for an entire group may be misleading and result in inappropriate conclusions. There was a general, although not significant, trend in this study toward increasing bacterial counts with increased gloving time, whether or not Vaseline was applied. This is consistent with other studies’oY’s and is attributed to the fact that povidune-iodine has some persistence or residuai activity on the skin. Other products such as hexachlorophene and chlorhexidine gluconate bind to the stratum corneum much
-
No vaeeline
-0.17 -2.95 + 0.97 (k2.14)
-0.26 +3.15 t 0.01 (e1.98)
-267
-+ 0.36 +0.46
(+ 1.76)
more effectively so that the chemical remains active on the skin.‘6 Rotter et al.ls reported that treatment of hands with n-propanol resulted in a significantly greater reduction in flora after 3 hours of gloving than either povidone-iodine or chlorhexidine. It might be postulated that there would be a proliferation of flora when hands are covered with petroleum jelly. For one thing, it would seem that the petroleum jelly would cause an environment in which anaerobes would thrive. Second, organic material such as blood has been shown to interfere significantly with the activity of povidone-iodine.“! I3 Wilson et a1.,s however, found that disinfectantand lotiontreated skin had greater reductions in flora than control or disinfectant-treated skin alone. In this study, the absence of any sign&cant effect of Vaseline treatment on flora of the hands is somewhat surprising. However, it appears that petroleum jelly on the skin is rather benign. On the basis of our data, we conclude that the application of sterile petroleum jelly to the hands before gloving is probably safe and may reduce the drying effects of handwashing. We thank Maureen A. Stephens, need for this study.
R.N., fur suggesting
the
1. Larson E, Killen M. Factors influencing handwashing behavior of patient care personnel. AB&3 f#FECT CCINTROL 1982;10:93-9.
Volume 15 Number August 1987
4
Emollient on &wed hands
2. Larson E. Handwashing and skin: physiologic and bacteriologic aspects. Infect Control 1985;6:14-23. 3. Larson E, Leyden J, McGinley K, Grove G, Talbot G. Physiologic and microbiologic changes in skin related to frequent handwashing. Infect Control 1986;7:59-63. 4. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg 1978;81:99-105. 5. Wilson K, Ayers L, Stone K. The effects of chlorhexidine and an emollient on human microbial skin flora. Proceedings of Thirteenth Annual Educational Conference. Las Vegas: Association for Practitioners in Infection Control, 1986:lOO. 6. Larson EL, Strom MS, Evans CA. Analysis of three variables in sampling solutions used to assay bacteria of hands. J Clin Microbial 1980;12:355-60. 7. Spradlin CT. Bacterial abundance on hands and its implications for clinical trials of surgical scrubs. J Clin Microbial 1980;11:389-93. 8. Michaud RN, McGrath MB, Goss WA. Improved experimental model for measuring skin degerming activity on the human hand. Antimicrob Agents Chemother 1972;2:8-15. 9. Aly R, Maibach HI. Factors controlling skin bacterial
10.
11. 12.
Bound volumes available
13. 14. 15. 16.
17f
flora. In: Maibach H, Aly R, eds. Skin microbiology. New York: Springer-Verlag, 1981:29-39. Aly R, Maibach HI. Comparative evaluation of chlorhexidine gluconate (Hibiclens) and povidone-iodine (E-Z Scrub) sponge/brushes for presurgical hand scrubbing. Current Therapeutic Research 1983;34:740-5. Dineen P. An evaluation of the duration of the surgical scrub. Surg Gynecol Obstet 1969;126:1181-4. Eitzen HE, Ritter MA, Frence MLV, Gioe TJ. A microbiological in-use comparison of surgical hand-washing agents. J Bone Joint $urg 1979;61-A:403-6. Lowbury EJL, Lilly HA. The effect of blood on disinfection of surgeons hands. Br J Surg 1974;61: 19-2 1. Peterson AF, Rosenberg A, Alatary SD. Comparative evaluation of surgical scrub preparations. Surg Gyneco1 Obstet 1978;146:63-5. Rotter M, Koller W, Wewalka G. Povidone-iodine and chlorhexidine gluconate-containing detergents for disinfection of hands. J Hosp Infect 1980; 1: 149-58. Bruch M. Newer germicides: what they offer. In: Maibath H, Aly R, eds. Skin microbiology. New York: Springer-Verlag, 1981:103-12.
to subscribers
Bound volumes of AMERICAN JOURNAL OF INFECTION CONTROL are available to subscribers (only) for the 1987 issues from the Publisher, at a cost of $24.00 ($30.00 international) for Vol. 15 (January-December). Shipping charges are included. Each bound volume contains a subject and author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146 USA; phone 800-325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.