Efficacy of hand disinfectants against vancomycin-resistant enterococci in vitro

Alcohol-Based Hand Sanitizers: Does Gelling Agent Really Matter?

Hand hygiene, social distancing, and face covering are considered the first protection against Coronavirus spreading. The high demand during the COVID-19 emergency has driven a frenetic production and marketing of hand sanitizer gels. Nevertheless, the effect of the gelling agent and its amount on the effectiveness of alcohol-based hand sanitizers (ABHSs) needs to be clarified. We presented a systematic study on the effect of the characteristics and concentration of the most employed excipients on the properties and antimicrobial activity of ABHSs. Three different gelling agents, carbopol, hydroxypropylmethylcellulose (HPMC), and hydroxyethylcellulose (HEC), at four different concentrations were used to prepare ABHSs. Viscosity, spreadability, delivery from commercial dispensers, evaporation rate, rubbing time, and hand distribution of the ABHSs were then explored. Biocidal activity of selected ABHSs was evaluated in vitro on ATCC and clinical strains. The studied ABHS can be considered bioactive and comfortable. Nevertheless, the cellulose polymers and ethanol interactions led to a slight but significant reduction in the biocidal activity compared with carbopol-based formulations. Our results underline the importance of the gelling agent properties and support the choice of carbopol as one of the best thickener agents in ABHS formulations.

Clinical application of skin antisepsis using aqueous olanexidine: a scoping review

Surgical site infections (SSIs) and catheter‐related bloodstream infections (CRBSIs) caused by bacteria from surfaces poorly disinfected with chlorhexidine gluconate (CHG) and povidone‐iodine (PVP‐I) are increasing. Olanexidine gluconate (OLG) was developed in 2015 in Japan to prevent SSI and CRBSI caused by bacteria resistant to CHG and PVP‐I. This scoping review aimed to identify the knowledge gap between what is known and what is not known about the disinfection efficacy of OLG. We searched MEDLINE through PubMed, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform search database, ClinicalTrials.gov, and the Web‐based database of Japanese medical articles for works published to July 18, 2021. Manual reference searches were also carried out. A total of 131 studies were screened. Forty‐seven studies were included in this review and classified into two major categories: studies on pharmacological effects and spectrum (n = 29) and studies on clinical and adverse effects (n = 18). Olanexidine gluconate showed bactericidal activity against methicillin‐resistant Staphylococcus aureus and vancomycin‐resistant enterococci, in addition to common Gram‐positive and Gram‐negative bacteria. In clinical settings, although there is limited evidence on SSI prevention, 1.5% OLG might be more effective than 10% PVP‐I and 1% CHG in preventing SSI. However, the clinical usefulness of OLG is unclear due to the limited number of clinical studies. Also, clinical research is limited to studies targeting SSI prevention, and there are no clinical studies on CRBSI. Further clinical studies are needed on SSI and CRBSI prevention.

Olanexidine gluconate versus povidone-iodine for preventing surgical-site infection in orthopaedic surgery: A retrospective study

BACKGROUND

Olanexidine gluconate (OLG) is a newly developed skin antiseptic, which is effective against a broad range of bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. The purpose of this study was to evaluate the bactericidal efficacy and safety of OLG in orthopaedic surgery.

METHODS

This retrospective study included a total of 1103 patients who underwent clean orthopaedic surgery. They were divided into two groups: 556 patients who were treated with OLG (OLG group), and 547 patients who were treated with povidone-iodine (PVP-I) (PVP-I group). The efficacy and the safety outcomes were measured as the rate of surgical-site infection (SSI) within 30 days after surgery and the rate of adverse skin reaction, respectively.

RESULTS

There was no significant difference between the OLG group and PVP-I group (1.80% vs. 2.38%; p = 0.50) based on the overall rate of SSI. Also, there was no significant difference in both superficial incisional infections (1.08% vs. 2.01%; p = 0.21) and deep incisional infections (0.72% vs. 0.37%; p = 0.35). The overall rate of adverse skin reaction was significantly higher in the OLG group than in the PVP-I group (2.16% vs. 0.73%; p = 0.047).

CONCLUSIONS

This retrospective study demonstrated that OLG has an efficacy similar to PVP-I in preventing SSI in clean orthopaedic surgery. However, adverse skin reactions at the application site of OLG requires more attention.

Increasing tolerance of hospital Enterococcus faecium to handwash alcohols

Alcohol-based disinfectants and particularly hand rubs are a key way to control hospital infections worldwide. Such disinfectants restrict transmission of pathogens, such as multidrug-resistant Staphylococcus aureus and Enterococcus faecium Despite this success, health care infections caused by E. faecium are increasing. We tested alcohol tolerance of 139 hospital isolates of E. faecium obtained between 1997 and 2015 and found that E. faecium isolates after 2010 were 10-fold more tolerant to killing by alcohol than were older isolates. Using a mouse gut colonization model of E. faecium transmission, we showed that alcohol-tolerant E. faecium resisted standard 70% isopropanol surface disinfection, resulting in greater mouse gut colonization compared to alcohol-sensitive E. faecium We next looked for bacterial genomic signatures of adaptation. Alcohol-tolerant E. faecium accumulated mutations in genes involved in carbohydrate uptake and metabolism. Mutagenesis confirmed the roles of these genes in the tolerance of E. faecium to isopropanol. These findings suggest that bacterial adaptation is complicating infection control recommendations, necessitating additional procedures to prevent E. faecium from spreading in hospital settings.

Enterococcus hirae, Enterococcus faecium and Enterococcus faecalis show different sensitivities to typical biocidal agents used for disinfection

BACKGROUND

Enterococcus faecium and E. faecalis are known nosocomial pathogens. The bactericidal activity of biocidal agents used for disinfection, however, is determined with E. hirae.

AIM

To find out whether E. hirae is a suitable species to evaluate the efficacy of biocidal agents against the clinically relevant species E. faecalis and E. faecium.

METHODS

The bactericidal activity was determined in suspension tests according to EN 13727 using E. faecium ATCC 6057, E. faecalis ATCC 47077 and E. hirae ATCC 10541. Glutaraldehyde, ethanol, benzalkonium chloride, peracetic acid and sodium hypochlorite were used with three exposure times per biocide. When major differences in the sensitivity of the three enterococcal species to the respective substance was found, two more replicates were performed. The number of colony-forming units (cfu) was transformed into decimal logarithms. Results from replicate experiments were described with means and standard deviations.

FINDINGS

At a 5-min exposure time, E. hirae was found to be more tolerant to 0.2% glutaraldehyde and 0.0125% peracetic acid compared to E. faecium and E. faecalis, whereas it was more susceptible to 40% ethanol and 3% sodium hypochlorite. Only with 0.00125% benzalkoniumchloride (15 min) was the susceptibility of E. hirae between that of E. faecium and E. faecalis.

CONCLUSIONS

E. hirae is a suitable species when a bactericidal activity should be determined against enterococci with glutaraldehyde and peracetic acid. E. hirae may not be a suitable species for ethanol or sodium hypochlorite if the bactericidal activity should include the clinical pathogens E. faecium and E. faecalis.

Evaluation of in Vitro Bactericidal Activity of 1.5% Olanexidine Gluconate, a Novel Biguanide Antiseptic Agent

Recently, 1.5% olanexidine gluconate, a biguanide compounds, was launched as a new antiseptic agent in Japan. However, the comprehensive bactericidal spectrum of olanexidine gluconate is still unknown. In this study, we evaluated in vitro bactericidal activity of olanexidine gluconate using time-kill assay against various bacteria, mycobacteria, and fungi. With the exception of Burkholderia cepacia and Mycobacterium spp., 1.5% olanexidine gluconate exhibited fast-acting (≤60 s) bactericidal activity against all tested Gram-positive and Gram-negative bacteria, including vancomycin-resistant Enterococcus faecalis, methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, extended spectrum β-lactamase producing Klebsiella pneumoniae, and multidrug-resistant Pseudomonas aeruginosa. Furthermore, 1.5% olanexidine gluconate eradicated Candida albicans, Microsporum canis, and Malassezia furfur within 3 min. Our findings indicate that olanexidine gluconate has broad spectrum bactericidal activity; therefore, it may be useful for the prevention of a wide range of infectious diseases.

Effects of olanexidine gluconate on preoperative skin preparation: an experimental study in cynomolgus monkeys

PURPOSE

To determine the bactericidal efficacy of a new topical antiseptic for preoperative skin preparation, olanexidine gluconate (development code: OPB-2045G), against transient or resident bacterial flora on the skin of cynomolgus monkeys.

METHODOLOGY

After measuring baseline bacterial counts on test sites marked on the abdomens, we applied olanexidine, chlorhexidine or povidone-iodine. After 10 min (fast-acting effect) and 6 h (long-lasting effect), bacterial counts were measured again and log10 reductions were calculated. In addition, we determined the bactericidal effects on the skin contaminated with blood before or after applying the antiseptics.

RESULTS

In the non-blood-contaminated condition, the mean log10 reductions of olanexidine at doses of 1-2 % were significantly higher than those of saline (negative control), but did not significantly differ from those of 0.5 % chlorhexidine and 10 % povidone-iodine at either time point. But olanexidine was significantly more effective at both time points than chlorhexidine and povidone-iodine when applied after the site was contaminated with blood. Olanexidine was also significantly more effective than chlorhexidine and as effective as or more effective than povidone-iodine at both time points when skin was contaminated with blood after the antiseptics were applied.

CONCLUSION

The bactericidal effects of olanexidine were comparable to those of commercial antiseptics such as chlorhexidine and povidone-iodine in non-blood-contaminated conditions. More importantly, the effect of olanexidine was hardly affected by blood unlike commercial antiseptics. Thus, it is considered that olanexidine has a favourable property for skin preparation in various types of surgical treatments.

Evaluation of the Antimicrobial Activity of a Super Oxidized Solution in Clinical Isolates

This study evaluated the antimicrobial activity of Estericide(®) QX (super oxidized solution) in 524 bacterial clinical isolates causing nosocomial infections. The minimum inhibitory concentration (MIC) was determined by the serial broth microdilution method. The bacterial viability of the isolates and control strains was tested. The bactericidal effect of the disinfectant was determined according to the European Standards (EN) Test Methods-1040 guidelines. Assay of stability in Estericide QX after 1 year of storage was performed. The microdilution assays showed that the isolates were inhibited at concentrations of 10-40 parts per million (ppm). For gram-positive bacteria, the MIC values 20 and 40 ppm were more predominant (95%), whereas for gram-negative bacteria, the MIC values 10 and 20 ppm had the highest percentage (91.7%). The difference between the two groups was statistically significant (p<0.001). The results of the assay of bactericidal activity showed that all tested bacteria (99.999%) were killed within 30 sec of contact time. The stability test showed that Estericide QX maintained its disinfectant action over time. In conclusion, the results of the present study showed that the super oxidized solution of Estericide QX provides a high antibacterial activity on both gram-positive and gram-negative bacteria. Based on these results and under the conditions of the present study, we believe that Estericide QX can be used efficiently against multiresistant nosocomial bacteria, providing an opportunity for new disinfection alternatives.

Bactericidal Effects and Mechanism of Action of Olanexidine Gluconate, a New Antiseptic

Olanexidine gluconate [1-(3,4-dichlorobenzyl)-5-octylbiguanide gluconate] (development code OPB-2045G) is a new monobiguanide compound with bactericidal activity. In this study, we assessed its spectrum of bactericidal activity and mechanism of action. The minimal bactericidal concentrations of the compound for 30-, 60-, and 180-s exposures were determined with the microdilution method using a neutralizer against 320 bacterial strains from culture collections and clinical isolates. Based on the results, the estimated bactericidal olanexidine concentrations with 180-s exposures were 869 μg/ml for Gram-positive cocci (155 strains), 109 μg/ml for Gram-positive bacilli (29 strains), and 434 μg/ml for Gram-negative bacteria (136 strains). Olanexidine was active against a wide range of bacteria, especially Gram-positive cocci, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, and had a spectrum of bactericidal activity comparable to that of commercial antiseptics, such as chlorhexidine and povidone-iodine. In vitro experiments exploring its mechanism of action indicated that olanexidine (i) interacts with the bacterial surface molecules, such as lipopolysaccharide and lipoteichoic acid, (ii) disrupts the cell membranes of liposomes, which are artificial bacterial membrane models, (iii) enhances the membrane permeability of Escherichia coli, (iv) disrupts the membrane integrity of S. aureus, and (v) denatures proteins at relatively high concentrations (≥160 μg/ml). These results indicate that olanexidine probably binds to the cell membrane, disrupts membrane integrity, and its bacteriostatic and bactericidal effects are caused by irreversible leakage of intracellular components. At relatively high concentrations, olanexidine aggregates cells by denaturing proteins. This mechanism differs slightly from that of a similar biguanide compound, chlorhexidine.

Novel antiseptic compound OPB-2045G shows potent bactericidal activity against methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus both in vitro and in vivo: a pilot study in animals

There is a need for new compounds to effectively treat methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). The novel monobiguanide compound 1-(3,4-dichlorobenzyl)-5-octylbiguanide gluconate (OPB-2045G) has potential bactericidal activity. We sought to elucidate the potency of OPB-2045G bactericidal activity against MRSA and VRE compared to those of chlorhexidine digluconate (CHG) and povidone iodine (PVP-I). In vitro bactericidal activity was analysed using minimum bactericidal concentration (MBC) as the index. The in vivo bactericidal efficacy of OPB-2045G was examined by determining MRSA and VRE contamination of the normal dorsal skin of mice following removal of hair. After a 3 min treatment period, the MBC of OPB-2045G was lower than that of CHG and PVP-I against standard strains and clinical isolates. Additionally, in our in vivo mouse model, the in vivo bactericidal activity of 1.5 % OPB-2045G (a clinically relevant dose) was higher than that of 0.5 % CHG and equivalent to that of 10 % PVP-I against MRSA. Similarly, the in vivo bactericidal activity of OPB-2045G was higher than that of 0.5 % CHG and 10 % PVP-I against VRE. OPB-2045G showed more potent bactericidal activity against MRSA and VRE both in vitro and in vivo compared to CHG and PVP-I, indicating that OPB-2045G may provide better protection against health care-associated infections caused by these pathogens.

Clinical use of the antiseptic polihexanide for genital tract infections

BACKGROUND

In clinical practice, treatment of genital tract infections is based on administration of either antibiotics or antiseptics. While antibiotics may be applied systemically or topically, antiseptics may be applied only topically. In case of bacterial vaginosis (BV), antibiotic therapy may often be limited and side effects due to systemic administration may develop. Polihexanide (PHMB) is a promising option for the topical treatment of genital tract infections, in particular BV and vaginitis.

METHOD

A systematic search for publications on the use of PHMB for the treatment of genital infections in two electronic databases was performed. Titles, abstracts and citations were imported into a reference database. Duplicates were removed and two reviewers assessed each identified publication separately.

RESULTS

Among a total of 204 references, 3 prospective randomized trials were identified. Two trials treated BV infections with PHMB in comparison to clindamycin as antibiotic standard therapy with no significant differences either in safety or in efficacy. The third controlled trial investigated the clinical efficacy of PHMB compared to placebo in the treatment of human papilloma virus. Patients treated with PHMB daily for up to 16-weeks showed significantly higher (52%) clearance of genital warts as compared to patients treated with placebo (4%).

CONCLUSION

PHMB may be a clinically effective alternative for the treatment of BV and human papilloma virus. Although PHMB-based antiseptics are available since the late 90s, controlled trials to investigate its clinical potential for antiseptic treatment are scant. Clinical use of antiseptics for the treatment of infectious diseases should be explored and supported further.

Presurgical hand antisepsis: concepts and current habits of veterinary surgeons

OBJECTIVE

To assess current habits for surgical hand preparation among veterinary surgical specialists and to compare data with current guidelines for hand asepsis techniques.

STUDY DESIGN

Survey of veterinary surgical specialists.

SAMPLE POPULATION

Diplomates of the American (ACVS) and European Colleges of Veterinary Surgeons (ECVS).

METHODS

An internet-based survey of hand preparation methods before surgical procedures was conducted of 1300 listed ACVS and ECVS Diplomates.

RESULTS

A 42.6% response rate was obtained. Approximately, 80% of respondents use disinfecting soaps as a primary method for hand antisepsis. Of those, 81% use chlorhexidine-based scrubs and 7% use a neutral soap followed by a hydroalcoholic solution.

CONCLUSIONS

Contrary to current recommendations of the World Health Organization and scientific evidence supporting use of hydro-alcoholic rubs for presurgical hand preparation, veterinary surgical specialists still use surgical scrub solutions containing disinfecting soaps.

Prevention of irritant contact dermatitis among health care workers by using evidence-based hand hygiene practices: a review

Irritant contact dermatitis is often found on the hands of healthcare workers and is generally caused by frequent hand washing, gloves, aggressive disinfectants or detergents. Alcohols have only a marginal irritation potential, although they may cause a burning sensation on pre-irritated skin. A burning sensation when using alcohols therefore, suggests that the skin barrier is already damaged. Two options for hand hygiene are generally available in clinical practice: (1) hand washing with some type of soap and water or (2) hand disinfection with alcohol-based hand rubs. Most clinical situations require the use of an alcohol-based hand rub for decontamination, which is especially useful for reducing the nosocomial transmission of various infectious agents. Washing one's hands should be the exception, to be performed only when they are visibly soiled or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids. The overall compliance rate in hand hygiene is around 50%, which is far too low. In addition, healthcare workers quite often wash their hands with soap and water, when they should use an alcohol-based hand rub. This not only adds to the degree of skin irritation, but is also potentially dangerous for patients, due to the low efficacy of hand washing when compared to hand disinfection with alcohol rubs. Adhering to evidence-based hand hygiene protocols and following international guidelines on hand hygiene practices therefore, can help prevent irritant contact dermatitis among healthcare workers.

Enterococcal Infection in Children

From relative obscurity, enterococci have become a leading cause of nosocomial infection. This has been attributed, in part, to the growth in susceptible host populations, increased use of intravascular devices, prolonged hospital stay, and widespread antibiotics use. Furthermore, the facility with which enterococci acquire resistance characteristics coupled with their capacity to survive in the environment renders them uniquely suited as nosocomial opportunists and have resulted in global dissemination of resistant strains. Debate continues as to whether most serious infections arise from a person's indigenous flora or dissemination of virulent clones. Enterococci are normal inhabitants of the human gastrointestinal tract. Classically associated with endocarditis and wound and urinary tract infections, increasingly they are a cause of nosocomial bacteremia. The rise in incidence of serious enterococcal infection has been particularly evident in neonatal, paediatric intensive care, and haematology/oncology units. Spread of resistant phenotypes has posed a difficult therapeutic challenge. We have been rescued, albeit perhaps only temporarily, by the addition of newer agents, such as linezolid, to the therapeutic armamentarium. However, there is no room for complacency. Linezolid resistance already has been reported. Efforts must continue to focus on prevention of the emergence and dissemination of resistance through policies of rational antibiotic use, infection control and education.

Hand hygiene: an evidence-based review for surgeons

This review of the literature discusses the scientific evidence behind using different hand hygiene agents on the surgical ward, and in theatre for preoperative disinfection. It considers the mechanism of action of the agents and their effectiveness against different pathogens, as well as possible future agents, and how they are tested. It addresses problems such as the poor compliance with hand hygiene guidelines by healthcare workers (especially doctors) and investigates what can be done to improve compliance. Finally, it demonstrates the reduction in hospital acquired infection (HAI) rate that can be achieved by improving hand hygiene compliance, and shows that the savings associated with this easily outweigh the cost.

Insufficient neutralization in testing a chlorhexidine-containing ethanol-based hand rub can result in a false positive efficacy assessment

BACKGROUND

Effective neutralization in testing hand hygiene preparations is considered to be a crucial element to ensure validity of the test results, especially with the difficulty to neutralize chlorhexidine gluconate. Aim of the study was to measure the effect of chemical neutralization under practical test conditions according to EN 1500.

METHODS

We have investigated two ethanol-based hand rubs (product A, based on 61% ethanol and 1% chlorhexidine gluconate; product B, based on 85% ethanol). The efficacy of products (application of 3 ml for 30 s) was compared to 2-propanol 60% (v/v) (two 3 ml rubs of 30 s each) on hands artificially contaminated with Escherichia coli using a cross-over design with 15 volunteers. Pre-values were obtained by rubbing fingertips for 1 minute in liquid broth. Post-values were determined by sampling immediately after disinfection in liquid broth with and without neutralizers (0.5% lecithin, 4% polysorbate 20).

RESULTS

The neutralizers were found to be effective and non-toxic. Without neutralization in the sampling fluid, the reference disinfection reduced the test bacteria by 3.7 log10, product B by 3.3 log10 and product A by 4.8 log10 (P = 0.001; ANOVA). With neutralization the reference disinfection reduced the test bacteria by 3.5 log10, product B by 3.3 log10 and product A by 2.7 log10 (P = 0.011; ANOVA). In comparison to the reference treatment Product B lead to a lower mean reduction than the reference disinfection but the difference was not significant (P > 0.1; Wilcoxon-Wilcox test). Without neutralizing agents in the sampling fluid, product A yielded a significantly higher reduction of test bacteria (4.8; P = 0.02) as compared to the situation with neutralizing agents (2.7; P = 0.033).

CONCLUSION

The crucial step of neutralization lies in the sampling fluid itself in order to stop any residual bacteriostatic or bactericidal activity immediately after the application of the preparation, especially with chlorhexidine gluconate-containing preparations. This is particularly important at short application times such as the 30 s.

Efficacy of two distinct ethanol-based hand rubs for surgical hand disinfection -- a controlled trial according to prEN 12791

Background

Aim of the study was to determine the efficacy of two distinct ethanol-based hand rubs for surgical hand disinfection in a controlled cross-over trial according to prEN 12791.

Methods

20 subjects were included. Hands were washed for 1 min with soap. The bacterial prevalue was obtained by rubbing finger tips in TSB for 1 min. Then, each subject treated the hands with the reference procedure (n-propanol, 60% v/v) or the product (Sterillium^® Rub, based on 80% ethanol; Avagard, based on 61% ethanol and 1% chlorhexidine gluconate) which were all applied in 3 to 4 portions each of 3 ml for a total of 3 min. Bacterial postvalues (immediate effect) were taken from one hand, the other hand was gloved for 3 h. After gloves were taken off the second postvalue was taken for the assessment of a sustained effect.

Results

Bacterial pre-values were between 4.38 ± 0.66 and 4.46 ± 0.71. Sterillium^® Rub achieved the required immediate (mean log₁₀-reduction of 2.59 ± 1.19) and sustained effect (1.73 ± 1.08) compared with the reference treatment (immediate effect: 2.58 ± 1.16; sustained effect: 1.67 ± 0.96). Avagard, however, did not achieve the required immediate (1.82 ± 1.40) and sustained effect (1.41 ± 1.08) in comparison to the reference disinfection (immediate effect: 2.98 ± 0.90; sustained effect: 2.56 ± 1.17; p < 0.01; Wilcoxon test).

Conclusion

Based on our data, Sterillium^® Rub can be regarded to be effective for surgical hand disinfection, but Avagard can not. The addition of 1% chlorhexidine gluconate to 61% ethanol (w/w) did not outweigh an ethanol concentration of 80% (w/w).

Assessment of the antibacterial activity of tea tree oil using the European EN 1276 and EN 12054 standard suspension tests

The activity of tea tree oil (TTO) and TTO-containing products was investigated according to the EN 1276 and EN 12054 European suspension methods. The activity of different concentrations of TTO, a hygienic skin wash (HSW), an alcoholic hygienic skin wash (AHSW) and an alcoholic hand rub (AHR) was investigated. These formulations were assessed in perfect conditions with the EN 12054 test, and in perfect conditions as well as in the presence of interfering substances with the EN 1276 test, against Staphylococcus aureus, Acinetobacter baumannii, Escherichia coli and Pseudomonas aeruginosa. With the latter test, the activity of the same formulations without TTO was also assessed as a control. With the EN 1276 test, the AHR achieved a >10(5)-fold reduction against all four test organisms within a 1-min contact time. The AHSW achieved a >or=10(5)-fold reduction against A. baumannii after a 1-min contact time and against S. aureus, E. coli and P. aeruginosa after a 5-min contact time. The efficacy of TTO appeared to be dependent on the formulation and the concentration tested, the concentration of interfering substances and, lastly, the organism tested. Nevertheless, 5% TTO achieved a >10(4)-fold reduction in P. aeruginosa cell numbers after a 5-min contact time in perfect conditions. TTO (5%) in 0.001% Tween 80 was significantly more active against E. coli and P. aeruginosa than against S. aureus and A. baumannii. With the EN 12054 test, after a 1-min contact time, 5% TTO in 0.001% Tween 80 and the AHSW achieved a >10(4)-fold reduction in E. coli and A. baumannii cell numbers, respectively, and the AHR achieved a >4 log10 reduction against all organisms tested. The formulations used in this study are now being tested using a novel ex vivo method as well as the in vivo European standard handwashing method EN 1499.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

In Vitro Efficacy of a Polyhexamethylene Biguanide-Impregnated Gauze Dressing Against Bacteria Found in Veterinary Patients

OBJECTIVE

To evaluate the in vitro efficacy of polyhexamethylene biguanide (PHMB)-impregnated gauze dressing in limiting the growth of bacteria both within and underneath the dressing.

STUDY DESIGN

In vitro study.

METHODS

Squares of PHMB-impregnated and control gauze were placed on agar plates inoculated with 1 of 11 bacterial species, including 8 multi-resistant organisms. Growth under the gauze was assessed qualitatively after 24-hour incubation. Repeated use of sponges was used to evaluate residual inhibitory activity against Micrococcus lutea and Staphylococcus schleiferi ss. schleiferi. In a second procedure, PHMB-impregnated and control gauze squares were placed in sterile plastic wells and inoculated with 1 of 5 bacterial species, including Pseudomonas spp. and Klebsiella spp. Inhibition of bacterial growth within and underneath the dressing after 24-hour incubation was evaluated by quantifying the numbers of bacteria on the well floor and within each square.

RESULTS

PHMB-impregnated gauze provided greater inhibition of growth of 4/4 Gram-positive species and 2/6 Gram-negative species on inoculated plates compared with control gauze. Residual inhibitory activity of PHMB-impregnated gauze was significantly greater against M. lutea on all days and against S. schleiferi ss. schleiferi on days 1 and 4 compared with control. No bacteria were recovered from inoculated PHMB-impregnated gauze squares placed in sterile wells or from the well floor underneath. More than 9 x 10(5) colony-forming units (CFU) were recovered from inoculated control samples placed in sterile wells and more than 8.4 x 10(4) CFU were recovered from control well floors.

CONCLUSION

PHMB-impregnated gauze dressing, when placed on inoculated agar plates, reduces growth of underlying bacteria, particularly Gram-positive species. Wet-inoculated PHMB-impregnated dressing prevents growth of Gram-positive and Gram-negative bacteria both within and underneath the dressing.

CLINICAL RELEVANCE

PHMB-impregnated dressings may be useful for reducing contamination of underlying wounds by bacterial pathogens.

A systematic review on the effectiveness of alcohol-based solutions for hand hygiene

The use of alcohol has been proposed as an option for hand hygiene. A systematic review was conducted to evaluate the clinical evidence supporting the use of alcohol-based solutions in hospitals as an option for hand hygiene. Studies published between January 1992 and April 2002 in English and Thai, related to the effectiveness of alcohol-based solutions, were reviewed. The databases searched included Medline, DARE, CINAHL and Dissertation Abstracts International. All studies were assessed as having adequate methodological quality. Results of this systematic review supported that alcohol-based hand rubbing removes microorganisms effectively, requires less time and irritates hands less often than does handwashing with soap or other antiseptic agents and water. Furthermore, the availability of bedside alcohol-based solutions increases compliance with hand hygiene among health care workers.

The effects of test variables on the efficacy of hand hygiene agents

BACKGROUND

Hand hygiene is essential to interrupting disease transmission in health care facilities. Multiple hand hygiene agents are currently available for use in the health care setting. To evaluate the utility of these agents, both the user acceptability and the efficacy need to be evaluated. Different hand hygiene test methodologies have been used to measure the efficacy of these agents, but efficacy results vary depending on variations to key parameters in these methodologies. The purpose of this study was to evaluate the effect of test variables on the efficacy of hand hygiene agents.

METHODS

Both a comprehensive literature review and original hand hygiene efficacy studies were undertaken. The literature review was conducted using a Medline search, and hand hygiene efficacy studies were conducted under the American Society for Testing and Materials (ASTM). E 1174 Standard Test Method for Evaluation of the Effectiveness of Health Care Personnel Handwash Formulation.

RESULTS

The literature review and our original data showed that the following variables affected the hand hygiene efficacy measurements: hand jewelry, experimental contamination versus normal flora, method of application of test organism, hand hygiene agent, concentration of active ingredient, volume of hand hygiene agent, duration of application of hand hygiene agent, method of application of hand hygiene agent, and study method (human challenge trial versus in vitro suspension test).

CONCLUSIONS

Although many methodological variables affect efficacy results, infection control professionals in their analysis of product information should always assess the results in light of the following key variables: concentration and type of active ingredient, duration of exposure to hand hygiene agent, volume of hand hygiene agent applied, test organism, and study method (ie, human challenge vs. in vitro suspension test).

Effectiveness of Alcohol-based solutions for Hand Hygiene: A Systematic Review

: Hand hygiene is an important measure in reducing the transmission of nosocomial infections in hospitals, but adherence is poor among health care workers (HCWs).More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol.Hand rubbing with alcohol-based products is commonly used in some countries instead of handwashing. This review evaluates the scientific and clinical evidence on the use of alcohol-based hand rubs in health care settings as a new option for hand hygiene.

OBJECTIVES

To conduct a systematic review to determine the best available evidence related to effectiveness of alcohol-based solutions for hand hygiene. The specific review questions addressed were: the effectiveness in reducing microorganisms, compliance with hand hygiene, and the incidence of skin problems. Application time (consumption) addressed efficiency.

CRITERIA FOR CONSIDERING STUDIES IN THIS REVIEW

This review considered all studies that included alcohol-based solutions that related to the objectives of the review. Outcomes included measures for the reduction of organisms, compliance with hand hygiene, the types of skin problems, and application time. The review primarily considered any intra-individual trials (IITs), randomised controlled trials (RCTs) and controlled clinical trials (CCTs) relating to the effectiveness of alcohol-based solutions but also included quasi-experimental designs.

SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES

The search sought to find published and unpublished studies. The databases searched included: Medline, CINAHL, ProQuest and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.

ASSESSMENT AND DATA EXTRACTION

All studies were checked for methodological quality by two reviewers and data were extracted using a tool.

DATA ANALYSIS

The study results were pooled in statistical meta-analysis using Review Manager software and summarized in narrative form where statistical pooling was not appropriate or possible.

RESULTS

This systematic review included thirty seven studies that supports the use of alcohol-based solutions for routine hand hygiene and surgical hand scrub. Alcohol-based hand rub removes microorganisms from hands of personnel more effectively, requires less time, and irritates hands less often than traditional handwashing with nonmedicated soap or other antiseptic agents and water. The combination of 61% ethanol and 1% chlorhexidine gluconate (CHG) is even more effective in producing residual antibacterial properties on the skin. Furthermore, the availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs.

CONCLUSION

Rubbing hands with alcohol-based agents has been proved to be effective in the reduction of microorganisms from hands. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Addition of CHG to alcohol-based solution can produce residual antibacterial properties on the skin. The use of alcohol-based solutions containing emollients causes less skin irritation and dryness and requires less time than washing hands with soap or other disinfectants. The promotion of bedside, alcohol-based hand rubs contributes to the increase in compliance with hand hygiene by HCWs.

Validity of the four European test strains of prEN 12054 for the determination of comprehensive bactericidal activity of an alcohol-based hand rub

A comprehensive bactericidal activity of an alcohol-based hand rub is essential for prevention of cross-transmission by the hands of healthcare workers. In Europe, however, only four test organisms are used to determine bactericidal activity according to prEN 12054. The susceptibility of the various bacterial species against the commonly used alcohols is thought to be similar, but so far this has never been studied. We therefore evaluated the bactericidal activity of an alcohol-based hand rub (Sterillium) within 30 s in compliance with prEN 12054 and in a time kill test against 13 Gram-positive, 18 Gram-negative bacteria and 14 antibiotic-resistant bacterial pathogens. Each strain was evaluated in quadruplicate. Counts of the four test bacteria of prEN 12054 were reduced by factors exceeding 10(5) within 30 s. In the time kill test, all 13 Gram-positive and all 18 Gram-negative bacteria were reduced more than 10(5)-fold within 30 s, not only against the ATCC test strains but also against corresponding clinical isolates. Comparable reductions were also observed against all 14 emerging bacterial pathogens. The four European test bacteria were found to be sufficient to determine a comprehensive bactericidal activity of a propanol-based hand rub.

Evaluation of the bactericidal effect of five products for surgical hand disinfection according to prEN 12054 and prEN 12791

Surgical hand disinfection (with an alcohol-based hand rub) and surgical handwash (with an antiseptic-based liquid soap) are accepted measures to reduce the risk for surgical site infections. The new European Standards allow a comparison of their antimicrobial efficacy. The bactericidal activity of surgical hand rubs [Sterillium and Softaman, (active ingredient=alcohols)] and handwashes [Derman plus (triclosan), Hibiscrub (chlorhexidine) and Betadine (PVP-iodine)] was tested according to the prEN 12054 suspension test using Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus hirae, and to prEN 12791 for the effect on resident skin flora in comparison with 1-propanol, 60% (v/v). All five products achieved a reduction of test bacteria within 3 min of >10(5)-fold so fulfilling prEN 12054. However, only Hibiscrub, Sterillium and Softa Man met the requirements of prEN 12791, giving a mean reduction of resident micro-organisms (immediate and sustained effect) which was not significantly lower than the reference alcohol (P>0.1; Wilcoxon matched-pairs signed-rank test). Sterillium was significantly more effective than the reference alcohol (immediate and sustained affect). Products for surgical hand disinfection may have equal antimicrobial activity in suspension tests but show large differences under practical conditions. Healthcare workers should not rely on results from suspension tests when deciding on a product for surgical hand disinfection.

Vancomycin-resistant enterococci: 15 years and counting

We review the history of vancomycin-resistant enterococci (VRE) and propose a causal model illustrating the roles of exposure to VRE reservoirs, patient characteristics, antimicrobial exposure, and prevalence of VRE in the progression from potential VRE reservoirs to active disease in hospitalized patients. Differences in VRE colonization and VRE infection are discussed with respect to hospital surveillance methodology and implications for interventions. We further document clonal transmission of VRE in a large, urban, teaching hospital and demonstrate VRE susceptibility to a wide array of antimicrobial agents. This model can guide the identification of mutable factors that are focal points for intervention.

State-of-the-art hand hygiene in community medicine

Hand hygiene becomes more important in community medicine not only since antibiotic resistant bacteria such as MRSA spread within the community. Hands may be colonized with transient microorganism in up to 75%. Among those transient pathogens S. aureus, C. difficile or the hepatitis C virus may be found. During patient care the number of microorganisms on the hands steadily increases. In addition hands may be contaminated with different kinds of germs even if only "clean" activities are carried out. Gloves may be worn but do not provide complete protection from contamination due to leaks. Therefore hands should always be treated after gloves are taken off. State-of-the-art treatment of hands is the hygienic hand disinfection with alcohol-based hand rubs. They are more effective, quicker to carry out, better tolerated by the skin, with a positive effect on compliance, and cost effective in comparison to antiseptic soaps based on chlorhexidine or triclosan and in comparison to normal non-medicated soaps. Healthy skin easily tolerates alcohol-based products from the beginning on. Only health care workers with an underlying irritative contact dermatitis which is often caused by bar or liquid antiseptic soaps may have difficulties to use alcohol-based products initially. In such a case treatment of the underlying skin condition is the way to go and not staying with a preparation which has caused the dermatitis. All this knowledge is now reflected in current guidelines on hand hygiene. Beside liquids alcohol-based gels can be used if they have an antimicrobial activity equal to alcohol-based liquid preparations. Hand hygiene remains the single most important tool to avoid cross transmission of microorganisms between patients. This state-of-the-art hand hygiene should also be emphasized more in community medicine. This review may help to go the first step into this direction.

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Antibiotic resistance as an indicator of bacterial chlorhexidine susceptibility

The antibiotic and chlorhexidine (CHX) susceptibility of 70 distinct clinical isolates: Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus (not MRSA), Streptococcus pyogenes and Enterococcus faecalis (10 of each) were tested using minimal bactericidal (MBC) and/or minimal inhibitory (MIC) concentrations. Non-fermentative bacteria tolerated CHX at high concentrations; Gram-positive cocci, especially S. pyogenes, were the most susceptible. We found a good correlation between CHX and antibiotic susceptibility in both MIC and MBC among Gram-negative bacteria, and mainly in MBC among Gram-positive bacteria. Resistance to ciprofloxacin, imipenem, cefotaxime, ceftazidime, gentamicin and aztreonam appeared to indicate increased CHX resistance among Gram-negative bacteria. This finding gives clinicians the ability to predict CHX susceptibility according to routine antibiotic resistance testing.

Bactericidal activities of disinfectants against vancomycin-resistant enterococci

The bactericidal activities of 35 commercially available disinfectants against vancomycin-resistant enterococci (VRE) and vancomycin-sensitive enterococci (VSE) were investigated under both clean and dirty (albumin added) conditions using a microtitration plate method. No differences in bactericidal time were observed with any of the test disinfectants when comparing activity against VRE or VSE. Isopropyl alcohol (70 v/v%), alcohol-containing preparations such as Welpas, Wellup and Maskin W . ethanol solution, 0.2% of cation surfactant disinfectants such as Osvan solution 'daigo', Germitol 'Maruishi' 10% and Hyamine solution, and 0.5% of amphoteric compound disinfectants such as TEGO-51, Hygieel and Hypal No.3, were the most effective compounds when compared with other disinfectants. These results suggest that the use of a disinfectant with activity against VRE may be one appropriate method for preventing infections caused by this micro-organism.

Is it time for brushless scrubbing with an alcohol-based agent?

The practice of surgical scrubbing in perioperative settings is changing rapidly. This article presents information about eliminating the traditional scrub brush technique and using an alcohol formulation for surgical hand scrubs. Also covered are antimicrobial agents, relevant US Food and Drug Administration classifications, skin and fingernail care, and implementation of changes. The article challenges surgical team members to evaluate a new and different approach to surgical hand scrubbing.

Compliance with hand hygiene practice in pediatric intensive care

OBJECTIVE

To determine the frequency and predictors of compliance with hand hygiene (HH) practice in pediatric intensive care.

DESIGN

Observational, prospective cohort study performed from February to April 2000.

SETTING

Three intensive care units at a tertiary care children's hospital.

PARTICIPANTS

Nurses, physicians, respiratory therapists, and other healthcare workers.

METHODS

During 156 30-min daytime observation periods, an unidentified observer monitored 2811 opportunities for HH during patient care and recorded HH compliance.

MEASUREMENTS AND MAIN RESULTS

Average HH compliance was 34% (946/2811). It was higher (p < 0.001) among respiratory therapists (68%; 171/251) than physicians (37%; 157/426) or nurses (29%; 587/2031). Contact with body fluid secretions was associated with the highest compliance (77%; 46/60), and contact with wounds (71%; 10/14) or indwelling devices (66%; 110/167) were associated with somewhat lesser compliance. The following were important predictors of compliance (all p < 0.01): being a respiratory therapist (odds ratio [OR], 5.1); working in the neonatal intensive care unit (OR, 1.6); and contact with invasive devices (OR, 2.5), wounds (OR, 6.9), or body fluids (OR, 11.5). Compliance was lowest after interrupted patient-care activities (9%; OR, 0.15). Surprisingly, decreased patient-to-nurse ratio (mean, 1.3 +/- 0.3) or opportunities per hr of care (mean, 37 +/- 7) were not independent predictors of compliance.

CONCLUSIONS

Average HH compliance was low, but it increased during high-risk patient-care activities. Intensified efforts are necessary to increase caretakers' compliance and the awareness of the risk of bacterial contamination after interrupted patient-care activities.

Nosocomial transmission of antibiotic-resistant microorganisms

The spread of nosocomially acquired, antibiotic-resistant microorganisms has grown dramatically over the past 20 years and has increasingly attracted the attention of academic inquiry. This article reviews recent epidemiological data about the trends and patterns of nosocomial transmission, presents clinical studies investigating mechanisms of cross-transmission, and discusses recent literature on preventive strategies aimed at reducing hand-carriage of antibiotic-resistant pathogens.

Assessment of two hand hygiene regimens for intensive care unit personnel

OBJECTIVE

To compare skin condition and skin microbiology among intensive care unit personnel using one of two randomly assigned hand hygiene regimens: a 2% chlorhexidine gluconate (CHG)-containing traditional antiseptic wash and a waterless handrub containing 61% ethanol with emollients (ALC).

DESIGN

Prospective, randomized clinical trial.

SETTING

Two critical care units (medical and surgical) in a large, metropolitan academic health center in Manhattan.

SUBJECTS

Fifty staff members (physicians, nurses, housekeepers, respiratory therapists) working full time in the intensive care unit.

INTERVENTIONS

One of two hand hygiene regimens randomly assigned for four consecutive weeks.

MEASUREMENTS AND MAIN RESULTS

The two outcomes were skin condition (measured by two tools: Hand Skin Assessment form and Visual Skin Scaling form) and skin microbiology. Samples were obtained at baseline, on day 1, and at the end of wks 2 and 4. Participants in the ALC group had significant improvements in the Hand Skin Assessment scores at wk 4 (p = 0.04) and in Visual Skin Scaling scores at wks 3 (p = 0.01) and 4 (p = 0.0005). There were no significant differences in numbers of colony-forming units between participants in the CHG or ALC group at any time period. The ALC regimen required significantly less time than the CHG regimen (mean: 12.7 secs and 21.1 secs, respectively; p = 0.000) and resulted in a 50% reduction in material costs.

CONCLUSIONS

Changes in hand hygiene practices in acute care settings from the traditional antiseptic wash to use of plain, mild soap and an alcohol-based product should be considered. Further research is needed to examine the association between use of antiseptic products for hand hygiene of staff and reductions in nosocomial infection rates among patients.

Infection control measures to limit antimicrobial resistance

Increasing antimicrobial resistance has resulted in a rapidly decreasing array of therapeutic options for infections in the critical care setting. Reports of reduced susceptibility to vancomycin in Staphylococcus aureus raise the possibility of patients being infected with a virulent pathogen for which most antibiotics are ineffective. Infection control methods to contain resistance, exclusive of antimicrobial restrictions, focus on surveillance to identify carriers of resistant organisms, prevention of nosocomial infections, adequate hand hygiene, isolation of patients who harbor resistant organisms, and the use of barrier techniques such as gowns and gloves. Surveillance using clinical isolates alone is inadequate for the identification of the majority of patients who carry resistant organisms. However, it is unclear what intensity of surveillance is needed to control the spread of these organisms in the intensive care unit in nonoutbreak situations. Attempts at eradicating carriage are often unsuccessful when there is extranasal colonization with methicillin-resistant S. aureus. Transmission of resistant organisms is primarily the result of transient contamination of healthcare workers' hands. Adequate handwashing, isolation of carriers, and barrier techniques are all necessary for containing resistance within the intensive care unit, however, compliance with these measures can be compromised by high staff turnover and heavy workload.

Comparison of different regimens for surgical hand preparation

Twenty surgical staff members participated in a clinical trial to compare the microbiology and skin condition of hands when using a traditional surgical scrub (TSS) with a detergent-based antiseptic containing 4% chlorhexidine gluconate (CHG) and a short application without scrub of a waterless hand preparation (HP) containing 61% ethyl alcohol, 1% CHG, and emollients. The HP was associated with less skin damage (P = .002) and lower microbial counts postscrub at days five (P = .002) and 19 (P = .02). The HP protocol had shorter contact time (HP mean [M] = 80.7 seconds; TSS M = 144.9 seconds; P < .0001), and more subjects preferred the HP regimen (P = .001). The HP performed better than the TSS, was less costly, and should be evaluated in larger trials and considered for widespread implementation.