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ALCOHOL FOR HAND HYGIENE:
NEW COMPARATIVE STUDIES ADD
TO THE EVIDENCE BASE
Two recent studies from France have added to the evidence
that hand disinfection with alcohol or alcohol based solutions is an essential
component of infection control. The first addresses hand hygiene on the
wards and the second in the operating theatre. These are quite different
scenarios.
Hand hygiene on wards requires rapid treatment to kill
or remove contaminants acquired by touch (“transient contaminants”),
for example from patients' skin or inanimate surfaces. Girou et al(1)
compared the effects of 3-5 mL of alcohol (a mixture of propan- 1-ol and
propan-2-ol, totalling 75% alcohol) with aqueous chlorhexidine handwash
on the reduction of naturally acquired transient contamination present
on ward staff hands after patient contact. (Most previous studies have
used artificially applied contamination.) The alcohol was rubbed into
the hands until it evaporated, the chlorhexidine was used as a handwash.
The alcohol handrub gave a significantly better reduction in bacteria
recovered from the hands than did the aqueous handwash (83% v 58%; p
= 0.012).
To be effective in practice, any hand hygiene procedure
must not only produce a substantial kill or removal of contaminating micro-
organisms but must also fit conveniently into ward routines. Although
both the washing and alcohol handrub took 30 seconds, handwashing requires
the individual to move to a sink and remain there throughout the process
for the handwashing agent, water, paper towels and disposal bin. Even
in new wards, handwashing sinks can be too far from some beds to make
handwashing convenient. Alcohol handrubs are likely to be more convenient;
after the agent is dispensed into the hands, the individual need not remain
at that point while rubbing the alcohol to dryness. Alcohol dispensers
can be wall mounted, free standing and dispersed around a ward, or in
small containers that can be carried around in staff pockets or attached
to trolleys.
There is substantial advocacy for ward hand-cleansing to
be based on alcohol handrubs; the United Kingdom Hand Hygiene Liaison
Group(2) recommends that alcoholic handrubs should be available
near every patient bedside and close contact areas for use on non-soiled
hands.
Surgical hand disinfection, in contrast to the hygienic
hand disinfection above, should kill or remove all micro-organisms on
surgeons' hands, and then suppress regrowth of the bacteria that
live on skin in the “greenhouse” conditions that wearing gloves
creates. Glove punctures during surgery are common and may not be obvious
to the glove wearer. Hand movement while wearing punctured gloves will
encourage fluid to pass into and out of the glove, depositing micro-organisms
derived from the surgeon's skin into the wound. These will usually
be of low pathogenic potential, but can present a real hazard in immunocompromised
individuals or where substantial non-self material is implanted, such
as orthopaedic prosthetic work. It has long been suggested that alcohol
hand-rubs could be considered as alternatives to traditional surgical
scrubs.
A paper by Parienti et al(3) compared the efficacy
and acceptability of agents used in surgical hand disinfection, in three
hospitals, on surgical site infection (SSI) rates by using a multiple
crossover experimental design. The agents studied were aqueous detergent
scrubs (either 4% povidone iodine or 4% aqueous chlorhexidine gluconate)
and the same alcohol mixture as in the Girou work above. The protocol
was to use aqueous detergents as traditional scrubs for at least 5 minutes
and the alcohol, following a plain soap wash at the start of the day,
as a handrub of two sequential 5 mL applications with a total rubbing
duration of 5 minutes. Excluding contaminated surgery, the surgical site
infection rates were 2.48% (53/2135) in the scrubbing group and 2.44%
(55/2252) in the handrub group. The difference between the groups was
not significant. However, observation of duration of preparation showed
better compliance when using alcohol than aqueous scrubs, and alcohol
produced less skin dryness and irritation.
Both papers noted problems in staff compliance with the
hand disinfection procedures. With the hygienic aqueous handwash(1),
65% of those observed lasted less than 30 seconds and with the surgical
handwash(3) compliance with duration was poor in the aqueous
handwash group (28%) and only marginally better in
the alcohol handrub group (44%; p = 0.008). Alcohol-based hand
disinfectants can only be part of the answer; education and encouragement
are also always needed.
References
1. Girou E, Loyeau S, Legrand P
et al. Efficacy of handrubbing with alcohol based solution versus standard
handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362-65.
URL: <http://bmj.com/cgi/reprint/325/7360/362.pdf>.
2. Cookson B, Teare L, May D et
al. Draft hand hygiene standards.
J Hosp Infect 2001;49:153.
3. Parienti JJ, Thibon P, Heller
R et al. Hand-rubbing with an aqueous alcoholic solution vs traditional
surgical hand-scrubbing and 30-day surgical site infection rates. A randomised
equivalence study. JAMA 2002;288:722-27. URL: <http://jama.ama-assn.org/issues/v288n6/
rpdf/joc20200.pdf>.
Source: Eurosurveillance, Vol
6, No 36, 2002.
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