4.1 The United States has concentrated attention and testing efforts on surgical scrubbing far more than on hand care in patient-to-patient routines. Great Britain, the originators of infection control nursing, have always had their focus on infection transmission. In the United States, published articles have documented the short exposure time for health care personnel who do wash their hands between patients. The average is less than 10 s. The ideal product for the reduction of transient flora is one that rapidly kills or removes or both the microbial load acquired during health care activities. The emphasis on rapidity is essential simply because health care personnel will not take the necessary time when using conventional hand-washing products. The use of products not intended for use with water has increased dramatically and their use is common in European countries largely because of convenience and effectiveness. A second characteristic is the level of antimicrobial action. The use of a rapid and potent active product to reduce work-acquired microbial flora is ideal.
4.2 Since the change from strictly in-vitro testing of topical antimicrobials for use on skin to simulated use testing in hand washing, prepping, site access testing, and sampling, emphasis has always been on washing hands, agitating, rubbing, and brushing with liquid on the skin site to estimate bacteria removed after testing.
4.3 The use of hard agitation has diminished with surgical scrubs without brushes or with only mild agitation and friction.
4.4 There is a history of microbial dispersal (9) and increase in surface bacteria from deeper layers resulting from showering (10-12), washing, scrubbing, and agitation. In the normal situation on the skin, there is a superficial, surface flora and a deeper or hidden flora (5). The proportion of one to the other has been addressed by Selwyn (4) and his judgment is that from 20 to 50 % of the flora is “deep.” The intent in skin sampling has almost always been to scrub, agitate, and use surfactant to remove as many organisms as we can. In doing this, we have completely ignored the two types of flora.
4.5 Further, when the skin is treated with a cleansing agent or an antimicrobial that is subsequently rinsed away, the “deep” or “hidden” flora is pushed to the surface as the sebum replenishes the sebum from the sebaceous glands removed in washing. Many early investigators have looked at simpler sampling methods that we now recognize were sampling primarily the superficial transient flora.
