Clinical double-blind trial on the dermal tolerance and user acceptability of six alcohol-based hand disinfectants for hygienic hand disinfection

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

A comparative study on the effect of alcohol-based hand sanitizers in spray and gel formulation on the skin: A prospective, randomised, crossover trial

BACKGROUND

Many formulations of Alcohol-based hand rubs (ABHRs), such as liquid, gel, and spray have been developed and used for preventing infections. This study aimed to compare skin irritation from using ABHRs in gel and spray formulations.

METHOD

This was a prospective, randomised, crossover trial conducted to investigate the effect of skin irritation caused by ABHRs in gel compared to spray formulation after 21 days of using each formulation. Clinical outcomes were assessed using subjective Larson's skin assessment score and Frosch and Kligman observer skin assessment score, as well as bioengineering measures: transepidermal water loss (TEWL) and skin capacitance on days 3, 7, 14, and 21.

RESULTS

Among 38 participants, both formulations showed no significant change in clinical scores and skin capacitance during the study. However, TEWL increased significantly from baseline on day 3 (p = 0.029) for the spray formulation and on day 21 (p = 0.019) for the gel formulation, with no statistically significant difference between the formulations (p = 0.46).

CONCLUSION

Our research supports the safety of gel and spray ABHRs for regular use, with the only potential issue being mild skin irritation. For those with sensitive skin, the gel formulation is preferable.

Ethanol is indispensable for virucidal hand antisepsis: memorandum from the alcohol-based hand rub (ABHR) Task Force, WHO Collaborating Centre on Patient Safety, and the Commission for Hospital Hygiene and Infection Prevention (KRINKO), Robert Koch Institute, Berlin, Germany

BACKGROUND

The approval of ethanol by the Biocidal Products Regulation has been under evaluation since 2007. This follows concern over alcohol uptake from ethanol-based hand rubs (EBHR). If ethanol is classified as carcinogenic, mutagenic, or reprotoxic by the European Chemicals Agency (ECHA), then this would affect infection prevention and control practices.

AIM

A review was performed to prove that ethanol is toxicological uncritical and indispensable for hand antisepsis because of its unique activity against non-enveloped viruses and thus the resulting lack of alternatives. Therefore, the following main points are analyzed: The effectiveness of ethanol in hand hygiene, the evidence of ethanol at blood/tissue levels through hand hygiene in healthcare, and the evidence of toxicity of different blood/tissue ethanol levels and the non-comparability with alcoholic consumption and industrial exposure.

RESULTS

EBHR are essential for preventing infections caused by non-enveloped viruses, especially in healthcare, nursing homes, food industry and other areas. Propanols are effective against enveloped viruses as opposed to non-enveloped viruses but there are no other alternatives for virucidal hand antisepsis. Long-term ingestion of ethanol in the form of alcoholic beverages can cause tumours. However, lifetime exposure to ethanol from occupational exposure < 500 ppm does not significantly contribute to the cancer risk. Mutagenic effects were observed only at doses within the toxic range in animal studies. While reprotoxicity is linked with abuse of alcoholic beverages, there is no epidemiological evidence for this from EBHR use in healthcare facilities or from products containing ethanol in non-healthcare settings.

CONCLUSION

The body of evidence shows EBHRs have strong efficacy in killing non-enveloped viruses, whereas 1-propanol and 2-propanol do not kill non-enveloped viruses, that pose significant risk of infection. Ethanol absorbed through the skin during hand hygiene is similar to consumption of beverages with hidden ethanol content (< 0.5% v/v), such as apple juice or kefir. There is no risk of carcinogenicity, mutagenicity or reprotoxicity from repeated use of EBHR. Hence, the WHO Task Force strongly recommend retaining ethanol as an essential constituent in hand rubs for healthcare.

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.

Evaluation of the Residual Disinfection Effects of Commonly Used Skin Disinfectants against Viruses: An Innovative Contact Transmission Control Method

Lasting disinfection effects, that is, the residual disinfection effects (RDEs), of skin-coated disinfectants have rarely been considered for infection control owing to the challenges involved in the accurate evaluation of RDEs. In this study, we constructed a new skin evaluation model and determined the RDEs of existing disinfectants against viruses. Our results showed that ethanol and isopropanol had no RDE, whereas povidone-iodine, chlorhexidine gluconate, and benzalkonium chloride (BAC) exhibited RDEs, with 10% povidone-iodine and 0.2% BAC showing particularly strong RDEs. The RDE of 0.2% BAC was strong enough to reduce the median survival times of severe acute respiratory syndrome coronavirus-2, human coronavirus-OC43, and influenza virus from 670 to 5.2, 1300 to 12, and 120 to 4.2 min, respectively. Additionally, this strong RDE was maintained even 4 h after coating the skin. Clinical data also showed that the strong RDE of 0.2% BAC was maintained for more than 2 h. Thus, applying disinfectants with strong RDEs on the skin correlates with a reduction in virus survival time and appears to create a skin surface environment that is not conducive to virus survival. A prolonged reduction in virus survival decreases the contact transmission risk, thereby enabling stronger infection control.

Virgin coconut oil as prophylactic therapy against alcohol damage on skin in COVID times

Background

Increased frequency of using alcohol‐based hand sanitizers (ABHS) by consumers during COVID times have resulted in increased incidences of skin issues on palms.

Objective

(1) To quantify skin damage with increased usage frequency of ABHS by consumers and (2) To evaluate Virgin Coconut Oil (VCO) as natural prophylactic agent to counter the adverse effects.

Methods

In‐home usage study was carried out with 60 volunteers for a 15‐day intervention—Control Group: 6 applications per day of ABHS and Test Group: Overnight VCO use (6–8 drops) followed by 6× usage per day of ABHS. This leg included dermatological evaluation and WHO Self‐Assessment Scale for skin health. Another leg of measurement included non‐invasive instrumental study (Moisture & TEWL Probes, Tape Strip for protein content and IR spectroscopy for protein & lipid content) on forearm of 12 subjects (25–60 years age) with and without VCO application and repeated alcohol exposure.

Results

In‐home usage study established consumer experiencing skin protective effect of VCO in the context of ABHS onslaught. 25% increase in perceived moisture content was recorded for VCO users, using WHO Self‐Assessment Scale. Instrumental studies confirmed an increase in TEWL and decrease in lipids & protein content. Overnight VCO application resists the extraction which builds up with repeated application.

Conclusions

Current work provides evidence of compromised hand skin barrier with ABHS daily usage. Overnight VCO application helps prepare the skin for next day alcohol use. Based on the findings, a regimen of overnight VCO application on hands as a natural prophylactic is recommended.

Hydrogels in Hand Sanitizers

Hand hygiene can be considered a strategic key useful in the containment of infections such as COVID-19 both at home and in communities because it can dramatically reduce the widespread outbreak of infections. In case of the unavailability of soap and water, "instant" hand sanitizers are recommended because their application can be considered easy, versatile, quick and often less aggressive for the skin. For these reasons, alcoholic and alcohol-free hand rub gels can be considered the best performing formulations on the market. Together with disinfectants and antiseptic agents, hydrogels play a fundamental role in obtaining stable formulations and are easy to disperse, with a pleasant skin feel and an overall good performance. Several compounds commonly used in the pharmaceutical, cosmetic and food industry are available for this purpose, in particular, cellulose derivatives and synthetic polymers derivatives. Each of them is available in several grades, presenting different thickening behavior, rheological properties and compatibility with other ingredients, alcohols in particular. For all these reasons, it is important to explore hydrogel properties and behaviors in different contexts (i.e., hydroalcoholic and aqueous media) in order to develop new and performing hand rub gels, always taking into account the different international legal frameworks regarding disinfectant and sanitizing formulations.

How irritant are n-propanol and isopropanol? - A systematic review

BACKGROUND

The use of alcoholic-based hand rubs (ABHRs) is an important tool for hand hygiene, especially in times of the COVID-19 pandemic. Possible irritant effects of ABHR may prevent their use by persons at risk of infection.

METHODS

This systematic review is based on a PubMed search of articles published between January 2000 and September 2019 in English and German, and a manual search, related to the irritation potential of alcohol-based disinfectants restricted to n-propanol (1-propanol) and its structural isomer isopropanol (isopropyl alcohol, 2-propanol).

RESULTS

The majority of the included studies show a low irritation potential of n-propanol alone. However, recent studies provide evidence for significant barrier damage effects of repeated exposure to 60% n-propanol in healthy, as well as atopic skin in vivo. The synergistic response of combined irritants, (ie, a combination of n-propanol or isopropanol with detergents such as sodium lauryl sulfate) is greater, compared with a quantitatively identical application of the same irritant alone.

CONCLUSION

While recent studies indicate a higher risk of skin irritation for n-propanol and isopropanol than reported in the past, this risk still seems to be lower than that for frequent handwashing with detergents, as recommended by some to prevent COVID-19 infections.

Hand sanitisers amid CoViD-19: A critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand

The world is facing a medical crisis amid the CoViD-19 pandemic and the role of adequate hygiene and hand sanitisers is inevitable in controlling the spread of infection in public places and healthcare institutions. There has been a great surge in demand for hand sanitisation products leading to shortages in their supply. A consequent increase of substandard products in the market has raised safety concerns. This article, therefore, presents a critical review of hand sanitation approaches and products available on the market in light of the scientific evidence available to date. This review also provides a range of hand sanitisation product formulations, and manufacturing instructions to allow for extemporaneous preparations at the community and hospital pharmacies during this urgent crisis. In addition, this emergent situation is expected to continue, hence hand sanitisers will be in demand for an extended time, and the availability and purchase of substandard products on the market create an ongoing safety concern. Therefore, this article shall also provide various commercial organisations, interested in stepping forward the production and marketing of hand sanitisers, with a guide on the development of products of standardised ingredients and formulations.

Surgical hand rubbing versus surgical hand scrubbing: Systematic review and meta-analysis of efficacy

BACKGROUND

Surgical hand rubbing (SHR) and surgical hand scrubbing (SHS) are two common methods used by surgeons to reduce surgical site infections. To date, the optimal method that can effectively reduce these infections remains unknown. In this study, we performed a comprehensive statistical analysis to compare the efficacy of these two methods in effectively controlling surgical site infections.

METHODS

A systemic review and meta-analysis was performed by mining literature from major databases, including Pubmed, Embase, Cochrane library, Ovid and Google Scholar, and recruiting studies published between 1980 and 1st April 2019. Analysis was performed using Revman, version 5.3, software, and focused on primary outcomes that included colony-forming unit (CFU) counts and logarithmic reduction of CFU after hand antisepsis and after surgery.

RESULTS

Seven clinical trials met our inclusion criteria, with a total of 764 healthcare workers analyzed. We found no statistically significant differences between the two methods with regards to CFU counts and logarithmic reduction of CFU after hand antisepsis and surgery, as well as antisepsis and surgery times.

CONCLUSION

From the literature, it was evident that SHR had similar efficacy to SHS, without necessarily increasing costs. Owing to advantages such as ease of application, exposure to less dermal irritation, and less time consumption, SHR is recommended as a cost-effective alternative for management of surgical site infections.

Skin barrier function after repeated short-term application of alcohol-based hand rub following intervention with water immersion or occlusion

BACKGROUND

Alcohol-based hand rub (ABHR) is recommended for hand hygiene, and application on dry skin is generally well tolerated. However, hydration of the skin may lead to increased susceptibility to ABHR.

OBJECTIVES

To evaluate if increased skin hydration changes skin barrier response to ABHR, as compared to application on dry skin.

METHODS

Twenty healthy volunteers participated in a 3-day experimental setup. Intervention areas on the forearms were exposed to either water immersion or occlusion followed by repeated exposures to ABHR. Skin barrier function was assessed by measurement of transepidermal water loss (TEWL), electrical conductance, pH, and erythema at baseline and day 3.

RESULTS

The area exposed to water immersion preceding ABHR showed a significant increase in TEWL from baseline to day 3 (P = .04), and for the occluded area the same trend was found (P = .11), with an additional decrease in electrical conductance (P = .03). No significant differences were found for the control area. The assessments did not differ significantly between intervention and control sites.

CONCLUSION

Our results indicate that extensive skin hydration may lead to increased susceptibility to ABHR. Further evaluation of this observation is important, since ABHRs are widely used, particularly among health care workers in whom hand eczema is a huge problem.

Assessment of tolerability and acceptability of an alcohol-based hand rub according to a WHO protocol and using apparatus tests

Background

The effectiveness of alcohol-based hand rubs (ABHRs) depends substantially on their acceptability and tolerability. In this study, we assessed the acceptability and tolerability of a new ABHR (product EU 100.2018.02).

Methods

Among physicians, nurses, and cosmetologists who used the ABHR for 30 days, we assessed the product’s acceptability and tolerability according to a WHO protocol. Additionally, we used instrumental skin tests. Participants assessed the product’s color, smell, texture, irritation, drying effect, ease of use, speed of drying, and application, and they gave an overall evaluation. Moreover, they rated the tolerability, i.e. their skin condition, on the following dimensions: intactness, moisture content, sensation, and integrity of the skin. The tolerability was also assessed by an observer as follows: redness, scaliness, fissures, and overall score for the skin condition. Instrumental skin tests included transepidermal water loss, skin hydration, sebum secretion, and percentage of skin affected by discolorations. All assessments were made at baseline (visit 1), and 3–5 days (visit 2) and 30 days (visit 3) later.

Results

We enrolled 126 participants (110 [87%] women) with a mean age of 34.3 ± 11.65 years. Sixty-five participants (52%) were healthcare professionals (physicians, nurses), and 61 (48%) were cosmetologists. During visit 2 and visit 3, about 90% of participants gave responses complying with the WHO’s benchmark for acceptability and tolerability. Similarly, the ABHR met the WHO criteria for observer-assessed tolerability: on all visits, in more than 95% of participants, the observer gave scores complying with the WHO benchmark. Transepidermal water loss decreased from baseline to visit 3 (p < 0.001), whereas skin hydration, sebum secretion, and the percentage of skin affected by discolorations did not change significantly during the study (p ≥ 130).

Conclusions

The EU 100.2018.02 had both high acceptability and tolerability, meeting the WHO criteria. The WHO protocol proved useful in the analysis of acceptability and tolerability of ABHRs.

Efficacy of application of an alcohol-based antiseptic hand rub or a 2% chlorhexidine gluconate scrub for immediate reduction of the bacterial population on the skin of dogs

OBJECTIVE To compare the efficacy of application of an alcohol-based antiseptic (80% ethyl alcohol) hand rub (ABAHR) with that of a 2% chlorhexidine gluconate scrub (CGS2) for immediate reduction of the bacterial population on the skin of dogs. ANIMALS 50 client-owned dogs with no evidence of skin disease. PROCEDURES On each dog, 2 areas of hair on the ventral aspect of the abdomen were clipped with a No. 40 blade and cleared of debris. A direct contact plate holding tryptic soy agar with polysorbate 80 and lecithin was gently pressed (for 2 seconds) on each skin site (preapplication sample). The CGS2 and ABAHR were each aseptically applied to 1 skin site on each dog. A direct contact plate was subsequently applied to each site in a similar manner (postapplication sample). All plates were cultured, and bacterial isolates were identified and quantified by the number of CFUs per plate. RESULTS Application of the CGS2 and ABAHR significantly decreased skin bacterial colony counts, compared with findings for preapplication samples. The number of CFUs per plate or postapplication percentage reduction in CFUs per plate did not differ between treatments. There were no adverse skin reactions associated with either application. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that applications of ABAHR and CGS2 were equally effective at immediately reducing the bacterial population on the skin of dogs, and there was no significant difference in percentage reduction in colony counts between the 2 applications.

Impact of hand sanitizer format (gel/foam/liquid) and dose amount on its sensory properties and acceptability for improving hand hygiene compliance

BACKGROUND

Effective alcohol-based hand rubs (ABHRs) and healthcare worker compliance with hand hygiene guidelines are important in the prevention of infection transmission in healthcare settings. Compliance to hand hygiene guidelines is affected by many factors including education, ABHR availability, time pressure, skin health, and user acceptance of the sensory properties of ABHRs during and after application.

AIM

To examine the effect of ABHR format (gel/foam/liquid) and dose (0.7 mL, 1.5 mL, 3 mL) on its sensory properties and acceptability, and to consider how this might affect healthcare workers' hand hygiene compliance.

METHODS

Sensory descriptive analysis established key sensory differences between ten market-leading ABHRs (three gels, four foams, two liquids, one aerosol foam). Focus groups reinforced these differences.

FINDINGS

All formats were less desirable at the highest dose as they were more difficult to handle than the lower doses. Foams and gels became stickier, less clean-feeling and slower to dry at higher doses. Liquids gave a cleaner, smoother, more moisturized feel, but the increased difficulty in handling and applying the product negated these benefits. Overall, the gel and foam formats were more desirable than the liquid. The key desirable properties include: fast absorption, soft/moisturized hand feel, not sticky, clean feel, and low smell.

CONCLUSION

The 1.5 mL dose yielded the most acceptable properties with no extreme negative consequences. The foam provided the benefits of both the liquid and gel and combined them into a more widely acceptable format that may lead to greater hand hygiene compliance.

Innovative Natural Ingredients-Based Multiple Emulsions: The Effect on Human Skin Moisture, Sebum Content, Pore Size and Pigmentation

The increased interest in natural cosmetics has resulted in a higher market demand for preservative-free products based on herbal ingredients. An innovative W/O/W type emulsions containing herbal extracts were prepared directly; its cation form was induced by an ethanolic rosemary extract and stabilized using weak herbal gels. Due to the wide phytochemical composition of herbal extracts and the presence of alcohol in the emulsion system, which can cause skin irritation, sensitization or dryness when applied topically, the safety of the investigated drug delivery system is necessary. The aim of our study was to estimate the potential of W/O/W emulsions based on natural ingredients for skin irritation and phototoxicity using reconstructed 3D epidermis models in vitro and to evaluate in vivo its effect on human skin moisture, sebum content and pigmentation by biomedical examination using a dermatoscopic camera and corneometer. According to the results obtained after in vitro cell viability test the investigated emulsion was neither irritant nor phototoxic to human skin keratinocytes. W/O/W emulsion did not cause skin dryness in vivo, despite the fact that it contained ethanol. We can conclude that the emulsion is safe for use as a leave-on product due to the positive effect on human skin characteristics or as a semisolid pharmaceutical base where active compounds could be encapsulated.

Shortening the Application Time of Alcohol-Based Hand Rubs to 15 Seconds May Improve the Frequency of Hand Antisepsis Actions in a Neonatal Intensive Care Unit

BACKGROUND For alcohol-based hand rubs, the currently recommended application time of 30 seconds is longer than the actual time spent in clinical practice. We investigated whether a shorter application time of 15 seconds is microbiologically safe in neonatal intensive care and may positively influence compliance with the frequency of hand antisepsis actions. METHODS We conducted in vitro experiments to determine the antimicrobial efficacy of hand rubs within 15 seconds, followed by clinical observations to assess the effect of a shortened hand antisepsis procedure under clinical conditions in a neonatal intensive care unit (NICU). An independent observer monitored the frequency of hand antisepsis actions during shifts. RESULTS All tested hand rubs fulfilled the requirement of equal or even significantly higher efficacy within 15 seconds when compared to a reference alcohol propan-2-ol 60% (v/v) within 30 seconds. Microbiologically, reducing the application time to 15 seconds had a similar effect when compared to 30-second hand rubbing, but it resulted in significantly increased frequency of hand antisepsis actions (7.9±4.3 per hour vs 5.8±2.9 per hour; P=.05). CONCLUSION Time pressure and workload are recognized barriers to compliance. Therefore, reducing the recommended time for hand antisepsis actions, using tested and well-evaluated hand rub formulations, may improve hand hygiene compliance in clinical practice. Infect Control Hosp Epidemiol 2017;38:1430-1434.

Effect of hand lotion on the effectiveness of hygienic hand antisepsis: Implications for practicing hand hygiene

BACKGROUND

Skin protection products should be used after washing hands with soap, during breaks, after work, and during leisure time. Aside from their beneficial effects, skin care products may also interact with alcohol-based hand disinfectants by reducing their efficacy. The aim of this study was to investigate the effect of a hand lotion on the effectiveness of hygienic hand antisepsis using an alcohol-based handrub.

METHODS

The effect of a protective hand lotion against an isopropyl alcohol-based handrub was investigated in 20 healthy volunteers according to the European standard test procedure EN 1500 in the following combinations: handwashing and application of hand lotion, only application of hand lotion, and no washing and no hand lotion (control), each for 5 minutes or 1 hour before hand antisepsis. The difference in microbiologic before-and-after values were expressed as log reduction factor.

RESULTS

The effectiveness of hand antisepsis was not significantly affected in any of the groups using the tested hand lotion.

CONCLUSIONS

Hand antisepsis may be delayed for 5 minutes after hand lotion application. Shorter time intervals might be possible but were not tested.

Effect of different alcohols on stratum corneum kallikrein 5 and phospholipase A2 together with epidermal keratinocytes and skin irritation

OBJECTIVES

The aim of this exploratory study was to investigate the effect of ethanol, isopropanol and n-propanol on stratum corneum (SC) enzymes and keratinocytes in vitro together with their effects on skin condition and function.

METHODS

Activities of kallikrein 5 (KLK5) and phospholipase A2 (PLA2) as well as keratinocyte metabolic activity, interleukin-1α (IL-1α) and tumor necrosis factor-α (TNF-α) were measured in vitro in the presence and absence of the different alcohols. We also measured transepidermal water loss (TEWL), skin capacitance, visual dryness and visual redness on the volar forearms of 25 Caucasian women following application of the alcohols 20 and 100 times per day over a period of 14 days in a clinical study.

RESULTS

Reduced activities of KLK5 and PLA2 were observed in the presence of the alcohols. The greatest denaturing effect was always observed for n-propanol (P < 0.001), and in the case of PLA2, the effect of isopropanol was greater than ethanol (P < 0.001). Equally, ethanol had the mildest effects on keratinocyte metabolic activity and cytokine secretion (P < 0.001) and n-propanol always produced the most severe changes in normal and differentiated keratinocytes. These in vitro findings supported the clinical results where the major effects were on the induction of skin irritation (increased dropout rates) and ranked the intolerance of the different alcohols as follows: n-propanol > isopropanol > ethanol. At the high application frequencies, the effect of the different alcohols on transepidermal water loss (TEWL) and skin capacitance was similar, but at the low application frequencies, n-propanol had a significant effect on TEWL and capacitance values (P < 0.05). Equally, n-propanol and isopropanol produced significantly more skin redness at the low application frequencies.

CONCLUSIONS

Clearly, isopropanol and n-propanol caused significant SC and keratinocyte perturbation in vitro together with damage to skin condition and function in vivo whereas ethanol did not. As a result, we show that ethanol-based sanitizers are better tolerated by skin, particularly in high-use settings, than other alcohols and should be the active ingredient of choice.

Reduction in Nosocomial Transmission of Drug-Resistant Bacteria After Introduction of an Alcohol-Based Handrub

Objective:

To assess quantitatively the clinical impact of using an alcohol-based handrub (ABHR) in the hospital environment, measuring impact as the incidence of new, nosocomial isolates of drug-resistant organisms.

Design:

An observational survey from 1998 to 2003 comparing the first 3 years of no ABHR use with the 3 years following, when an ABHR was provided for hand hygiene.

Setting:

An inner-city, tertiary-care medical center.

Intervention:

At baseline, an antimicrobial soap with 0.3% triclosan was provided for staff hand hygiene. The intervention was placement in all inpatient and all outpatient clinic rooms of wall-mounted dispensers of an ABHR with 62.5% ethyl alcohol. Data were collected on change in the incidence of three drug-resistant bacteria.

Results:

During the 6 years of the survey, all new, nosocomially acquired isolates of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile-associated diarrhea were recorded. On comparison of the first 3 years with the final 3 years, there was a 21% decrease in new, nosocomially acquired MRSA (90 to 71 isolates per year; P = .01) and a 41% decrease in VRE (41 to 24 isolates per year; P < .001). The incidence of new isolates of C. difficile was essentially unchanged.

Conclusion:

In the 3 years following implementation of an ABHR, this hospital experienced the value of reductions in the incidence of nosocomially acquired drug-resistant bacteria. These reductions provide clinical validation of the recent CDC recommendation that ABHRs be the primary choice for hand decontamination. (Infect Control Hosp Epidemiol 2005;26:650-653)

Adherence to surgical hand rubbing directives in a hospital district of Southwest Finland

BACKGROUND

The primary objective was to measure the compliance with alcohol-based surgical hand rubbing (SHR) among operation room personnel. The secondary objective was to evaluate the effect of feedback sessions on compliance.

METHODS

This was a prospective observational before-after intervention study. Between October 2010 and June 2012 the hygiene nurses observed SHR among operation room personnel in the hospital district of Southwest Finland. After feedback sessions a second observation round was conducted in the main operation room of Turku University Hospital. The first observation round comprised 477 observations: 259 (54%) were doctors, 190 (40%) nurses and 28 (5%) other personnel. In the second observation round a total of 210 observations were made.

RESULTS

During the first round in 42% of observations the 3 min SHR time recommended by WHO was used. Median times for SHR were 1 min 50 s (range 0 min to 5 min 44 s) for doctors and 3 min 25 s (range 1 min 1 s to 8 min 15 s) for nurses, respectively (p < 0.0001). In 40% of observations hands were not properly dried after a wash before applying SHR and in 45% hands were not allowed to dry properly after SHR before donning surgical gloves. After feedback, time for SHR did not significantly improve but technique did.

CONCLUSIONS

SHR was performed incorrectly in most observations even after feedback. The results stress the importance of more effective education, helping techniques and positive role models for operation room personnel to promote SHR.

Factors influencing field testing of alcohol-based hand rubs

BACKGROUND

According to the World Health Organization guidelines, field tests, in the context of a bid for the supply of alcohol-based hand rubs, should take into account climatic region, test period, products already in use, and type of use (hygienic or surgical) when assessing tolerance. This laborious method is often contested.

OBJECTIVE

To conduct a post hoc analysis of the data of a large bid, including 5 factors, to validate the relevance of their inclusion.

METHODS

For the purposes of the bid, products were compared in terms of the 4 World Health Organization tolerance criteria (appearance, intactness, moisture content, sensation) during product testing and were separated into groups on the basis of the studied factors. The post hoc analysis method included (1) comparison of the mean before-and-after difference based on the self-evaluation of the skin with the 4 World Health Organization tolerance criteria, between climatic regions, periods, products in use, test product, and the type of use; (2) generalized linear models, taking into account all studied factors.

RESULTS

The analysis included data for 1,925 pairs of professionals. The means of the differences observed were independently and significantly associated with the test period (P<.001), the hygienic or surgical use (P=.010 to .041, not significant for appearance), the product already in use (significant for appearance P=.021), and the test product (P<.001). The association with climatic region was found to be significant only in the nonadjusted analysis.

CONCLUSION

The type of use, the test period, and the product in use should be taken into account when designing field tests of alcohol-based hand rubs.

Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center

BACKGROUND

Hand hygiene is the cornerstone of aseptic techniques to reduce surgical site infection. Conventional surgical scrub is effective for disinfecting a surgeon's hands. However, the compliance of conventional scrub may be hindered by skin damage, allergy, and time. Alcohol-based hand rub has a satisfactory antimicrobial effect, but mostly in laboratory settings. Our aim was to compare a conventional surgical scrub with an alcohol-based hand rub to evaluate antimicrobial efficacy.

METHODS

From June 1, 2010 to July 31, 2011, 128 healthcare workers were enrolled in the study. They used an alcohol-based hand rub or a conventional surgical scrub as preoperative hand antisepsis during their routine practice. Hand sampling for cultures were performed before and after operations. Positive culture plates were further processed for pathogen identification.

RESULTS

The culture positive rate of the alcohol-based hand rub was 6.2% before operations and 10.8% after operations. Both rates were lower than the conventional surgical scrub [47.6% before operations (p < 0.001) and 25.4% after operations (p = 0.03)]. The most identified pathogens were Gram-positive with coagulase-negative staphylococci being the major pathogen. Multivariate analysis showed that prior hand condition (p = 0.21) and type of surgery such as cardiovascular surgery (p = 0.12) were less relevant, but the alcohol-based hand rub was a significant protective factor for positive hand cultures.

CONCLUSION

The alcohol-based hand rub was more efficacious for surgical antisepsis and had sustained efficacy, compared to conventional surgical scrub. We suggest that alcohol-based hand rubs could be an alternative surgical antiseptic in the operative theater.

Impact of health campaign on hand hygiene with alcohol-based hand rubs in a non-clinical setting

BACKGROUND

Hand hygiene has been acknowledged as the single most important measure to prevent nosocomial infections. Likewise, for non-clinical settings, hand hygiene is recognized as a key element to prevent the spread of infectious diseases, nevertheless poor compliance has been documented. The feasibility of hand hygiene interventions in open-community settings with adults is mostly unclear.

AIM

To investigate the acceptability and feasibility of a health campaign to promote hand hygiene with alcohol-based hand disinfectants at workplaces in a non-clinical setting.

METHODS

The surveys were conducted as part of a prospective, controlled intervention study with volunteers from the administration of the Ernst-Moritz-Arndt-University Greifswald, the municipality of Greifswald and the state of Mecklenburg-West Pomerania. Participants in the intervention group were provided with alcohol-based hand disinfection; the control group was unchanged. Eleven volunteers filled out an initial survey at the beginning of the intervention regarding demographic and health-related questions as well as questions about the type of work, and a survey after completion of the intervention to evaluate the study's impact on the participants' attitudes toward hand hygiene. Participants in the experimental group filled out a monthly questionnaire regarding their compliance with hand hygiene measures, feasibility of hand disinfection and possible side-effects.

FINDINGS

From 850 employees asked to participate, 134 were included in the study, and surveys from 129 participants (intervention: 64 vs control: 65) were accepted for analysis. Overall, datasets of 1230 person-months (79.46% of total possible follow-up surveys) were collected. Return rate and compliance remained high during the study period. Hand disinfection did not lead to skin problems in the majority of person-months. After the intervention, a majority of participants would favour a further use of hand disinfectants.

CONCLUSION

Campaigns that enforce the use of alcohol-based hand disinfectants can have a sustainable effect on the compliance with hand hygiene measures in non-clinical settings. Campaigns have been shown to be feasible and effective in the prevention of transmissible diseases, therefore employers should consider whether hand hygiene campaigns to introduce waterless hand rubs could be included in companies' health programmes.

Prospective observational study to assess hand skin condition after application of alcohol-based hand rub solutions

BACKGROUND

The use of alcohol-based hand rub solutions (ABHRSs) in health care settings has been associated with increased hand hygiene compliance and reduced rates of nosocomial infection. Deterioration in hand skin condition leads to impaired barrier function, changes in skin flora, and increased bacterial shedding. Thus, poor skin condition can increase the risk of infection. This study evaluated the hand skin condition and dermal tolerance among health care workers (HCWs) after ABHRS application.

METHODS

The study group comprised 231 HCWs (34% nurses, 22% nurse assistants, and 15% hospital cleaners). The mean participant age was 40 years. Stratum corneum hydration and superficial sebum content and surface pH of the skin were measured on the back and palm of each participant's dominant hand before and after ABHRS use. A self-assessment questionnaire was administered to collect information about the participants, their skin problems, and their perception of the ABHRS.

RESULTS

The study group was 83% females. Skin hydration at the 2 assessment sites was markedly increased after ABHRS use (P < .0001). The mean pH value did not change significantly on the back of the hand, but did change significantly on the palm (P = .012). The superficial sebum content decreased significantly on the palm (P < .0001), but not on the back of the hand. HCWs reported excellent or good skin tolerance of ABHRS in 73% of cases.

CONCLUSION

ABHRSs are well tolerated and do not dry the skin. pH and superficial sebum values decreased slightly, but these decreases did not affect skin barrier function. Values remained within the physiological range.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Eficácia de três métodos de degermação das mãos utilizando gluconato de clorexidina degermante (GCH 2%)

A degermação cirúrgica das mãos e dos antebraços é um procedimento que integra as atividades de paramentação cirúrgica como uma medida de prevenção de infecção do sítio cirúrgico. Com o advento dos princípios antissépticos degermantes, a necessidade do uso de escovas para a degermação cirúrgica tem sido questionada e recomendado o abandono deste uso devido às lesões provocadas na pele. Com a finalidade de fundamentar a eficácia da técnica da degermação cirúrgica sem o uso de escovas ou esponjas, o objetivo deste estudo foi avaliar três métodos para degermação cirúrgica utilizando a formulação degermante de gluconato de clorexidina - GCH 2%: com escova, com esponja e sem artefato. Foram avaliados 29 profissionais da saúde, utilizando o método de caldo de luva para coleta de micro-organismos antes e depois de cada método testado. As análises estatísticas comprovaram não haver diferenças estatísticas significantes na redução microbiana entre os três métodos analisados (p=0,148), o que teoricamente descarta a necessidade da continuidade do uso de escovas e esponjas para a realização da degermação das mãos.

Alcohol hand abuse: a cross-sectional survey of skin complaints and usage patterns at a large UK teaching hospital

OBJECTIVES

To investigate whether the regular use of alcohol hand gel was having a detrimental effect on hands of healthcare professionals and, if so, to what extent. The study also aimed to establish a link between individuals who felt their hands were suffering from persistent exposure to the gel and those who actively avoided using the gel.

DESIGN

A short descriptive questionnaire was distributed to healthcare professionals and those working within clinical areas within one trust (two teaching hospitals).

SETTING

Staff that worked or had duties within clinical areas that necessitated the use of alcohol hand gel.

PARTICIPANTS

The survey was sent via email to all staff on the email database.

MAIN OUTCOME MEASURE

To determine the number of staff that developed new onset skin conditions since the introduction of alcohol hand gel and of what proportion of this number actively or considered avoiding the hand gel.

RESULTS

Questionnaires were returned for analysis by 399 respondents. Eighty-eight percent of respondents felt that they had developed new onset skin conditions as a consequence of maintaining hand hygiene protocols. Nurses were the highest users of the hand gel, but interestingly were also the highest group to avoid or consider avoiding the hand gel (52% compared with 28%, 26% and 44% in the doctors, secretaries and healthcare assistants groups, respectively) .Thus indicating more frequent use may cause increased problems.

CONCLUSION

This study demonstrated that 88% of respondents stated that they had new-onset skin problems, of which half-felt that alcohol gel was the main contributing factor. There was a detrimental effect on compliance with alcohol gel hand hygiene protocols in this group. This reflects the real life difficulties of staff in their endeavour to reduce hospital-acquired infections. Action is needed to improve the compliance with such a simple task and ensure that all is done to reduce nosocomial infection and reduce the potential financial burden.

World Health Organization-recommended hand-rub formulations do not meet European efficacy requirements for surgical hand disinfection in five minutes

The World Health Organization (WHO) has recommended two hand-rub formulations for local production based on 80% ethanol or 75% isopropanol (both v/v). We have looked at their efficacy according to EN 12791. Twenty-six subjects treated their hands with the reference procedure (n-propanol, 60%) for 3 min or with one of the two formulations for 1.5, 3 or 5 min (Latin square design). Post-values (immediate effect) were taken from one hand, the other hand was gloved for 3 h. After the glove had been taken off, the second post-value was taken (3 h effect). The mean log(10) reduction of each hand rub at all three application times was compared to Hodges and Lehmann's reference procedure for non-inferiority. In the first block the reference procedure reduced bacterial load by 2.43 log(10) (immediate effect) and 2.22 log(10) (3 h effect). The efficacy of the ethanol-based formulation (e.g. immediate efficacy of 1.41 log(10) at 5 min) was inferior to the reference procedure at all application times [lower 95% confidence interval (CI): less than -0.75]. In the second block the reference procedure reduced bacterial load by 2.72 log(10) (immediate effect) and 2.26 log(10) (3 h effect). The efficacy of the isopropanol-based formulation (e.g. immediate efficacy of 2.05 log(10) at 5 min) was also inferior to the reference procedure at all application times (lower 95% CI: less than -0.75). Both WHO-recommended hand-rub formulations failed to meet the EN 12791 efficacy requirements for surgical hand disinfection within 5 min. A higher concentration of the active ingredients may improve the efficacy.

[Risk factors for dryness or irritation of staff hands in nine healthcare institutions]

OBJECTIVE

We performed a prospective multicenter study to assess dryness and irritation of hands of staff in care facilities, and to show that disinfection with alcohol-based hand rub is better tolerated than classic hand washing with mild soap.

METHOD

Dryness and irritation were self-evaluated by volunteers and hetero-evaluated by a team of investigators. The study took into account most of the individual and environmental risk factors of dryness and irritation (season, age, gender, use of protective agent, constitutional, personal and external factors, institution, function, number of consecutive working days).

RESULTS

The results from the 1932 assessments collected showed that traditional hand washing was a risk factor for dryness or irritation, while alcohol-based hand rubs caused no skin deterioration and had a protective effect even when used intensively.

COMMENT

These results should help to fight non-adherence to the use of alcohol-based hand rubs.

Effectiveness of alcohol-based hand disinfectants in a public administration: impact on health and work performance related to acute respiratory symptoms and diarrhoea

Background

The economical impact of absenteeism and reduced productivity due to acute infectious respiratory and gastrointestinal disease is normally not in the focus of surveillance systems and may therefore be underestimated. However, large community studies in Europe and USA have shown that communicable diseases have a great impact on morbidity and lead to millions of lost days at work, school and university each year. Hand disinfection is acknowledged as key element for infection control, but its effect in open, work place settings is unclear.

Methods

Our study involved a prospective, controlled, intervention-control group design to assess the epidemiological and economical impact of alcohol-based hand disinfectants use at work place. Volunteers in public administrations in the municipality of the city of Greifswald were randomized in two groups. Participants in the intervention group were provided with alcoholic hand disinfection, the control group was unchanged. Respiratory and gastrointestinal symptoms and days of work were recorded based on a monthly questionnaire over one year. On the whole, 1230 person months were evaluated.

Results

Hand disinfection reduced the number of episodes of illness for the majority of the registered symptoms. This effect became statistically significant for common cold (OR = 0.35 [0.17 - 0.71], p = 0.003), fever (OR = 0.38 [0.14-0.99], p = 0.035) and coughing (OR = 0.45 [0.22 - 0.91], p = 0.02). Participants in the intervention group reported less days ill for most symptoms assessed, e.g. colds (2.07 vs. 2.78%, p = 0.008), fever (0.25 vs. 0.31%, p = 0.037) and cough (1.85 vs. 2.00%, p = 0.024). For diarrhoea, the odds ratio for being absent became statistically significant too (0.11 (CI 0.01 - 0.93).

Conclusion

Hand disinfection can easily be introduced and maintained outside clinical settings as part of the daily hand hygiene. Therefore it appears as an interesting, cost-efficient method within the scope of company health support programmes.

Trial registration number

ISRCTN96340690

Microbiological efficacy and tolerability of a new, non-alcohol-based hand disinfectant

OBJECTIVE

Alcohol-based hand disinfectants are widely used in hospitals. Occasionally, there is a need for non-alcohol-based products, but alternatives have been scarce. We studied the microbiological efficacy and tolerability of a water-based hand disinfectant for healthcare workers.

DESIGN

A water-based hand disinfectant was introduced as the only hand disinfectant in 5 wards in Turku University Hospital, Finland. Ninety-nine healthcare workers participated in fingerprint sampling during the 7-week study period. In another ward, 26 healthcare workers who were using alcohol-based hand disinfectant acted as control subjects for the skin reaction studies. The water-based product was tested in the laboratory according to the European standard EN 12791. We obtained 292 fingerprint samples before disinfection and 302 after disinfection. The opinions of healthcare workers were collected by use of a questionnaire, and skin reactions were assessed subjectively by use of questionnaires and objectively by measuring moisture and transepidermal water loss.

RESULTS

When tested in accordance with the European standard, the product met the requirements for short-term and long-term efficacy. The results of the fingerprint test showed that there was a statistically significant decrease in colonization of the fingertips before and after disinfection (P<.001). The users of the water-based hand disinfectant reported dry skin more often than did control subjects, but visual inspection and the results of the moisture measurement showed no difference between the users of the water-based hand disinfectant and the control subjects. Transepidermal water loss measurement also showed no deterioration of skin condition.

CONCLUSIONS

The water-based hand disinfectant was shown to be an effective hand disinfectant that caused relatively little skin irritation and can serve as a hand hygiene alternative in situations in which alcohol-based disinfectant cannot be used.

Improving adherence to surgical hand preparation

At present, no universal agreement on detailed practice for surgical hand preparation exists. In order to fill this gap, in 2002 a Franco-German recommendation for surgical hand preparation was published as a first step towards a generally accepted European recommendation. Based on an assessment of the actual literature, a protocol for surgical hand preparation is discussed with the aim to recommend evidence-based standard procedures including prerequisites, washing and disinfection phase, and its practical implementation. In contrast to hygienic hand disinfection, for surgical hand preparation compliance is not an issue, since it mostly is regarded as a ceremony which is carried out without exception. Nevertheless, the following factors influence acceptance and efficacy: skin tolerance, ease of use, duration of procedure, and recommended time), potential for impaired efficacy due to incorrect performance of the procedure, possibility of systemic risks and irritating potential by applied preparations, religious restrictions, ecological aspects, costs and safety. Here, we report our experience with the introduction of a new hand preparation regime in all surgical disciplines in our university hospital based on the above factors. The following statements were evaluated: 1) The immediate efficacy of an alcohol-based hand disinfectant is impaired by a preceding hand wash for up to 10 minutes. Therefore hands should not be routinely washed before the disinfection period unless there is a good reason for it such as visible soiling. 2) A shortened application time (1.5 minutes) is equal to 3 min in terms of efficacy. 3) Hands should be air dried before gloves are put on, otherwise the perforation rate of gloves will increase. 4) The efficacy of alcohol-based disinfectants is significantly higher when hands are allowed to dry for 1 minute after the washing phase and before the disinfection phase. To clarify the above questions before the establishment of the modified technique, the surgical team was invited to a meeting. As a result, the heads of surgical departments supported the new technique and decided to change their practice.

Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group

BACKGROUND

Nurses have a high risk of developing hand eczema due to hand disinfection procedures.

OBJECTIVES

To investigate the perception of nurses regarding the adverse effects of hand washing (HW) and alcoholic disinfection (ADI), and to obtain data on the prevalence of hand dermatitis and sensitization to alcohols and alcohol-based hand rubs (ABHRs).

METHODS

A self-administered questionnaire survey, carried out as a pilot study (PS), followed by a modified multicentre study (MC) in five hospitals. Patch tests to ethanol (80%), 1-propanol (60%), 2-propanol (70%) and ABHRs were performed in a subsample.

RESULTS

The majority (PS 60.1%; MC 69.5%) of nurses considered ADI to be more damaging than HW. Mostly, ADI and HW were suspected to have irritant effects (ADI 79.2%/52.1%; HW 65.5%/36.2%) compared with an allergenic potential (ADI 10.4%/5.8%; HW 7.8%/3.9%). The prevalence of hand dermatitis in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions. In 50 tested individuals no sensitization and only two irritant reactions to alcohols and three single-positive reactions to ABHRs were observed, none of the latter related to alcohols.

CONCLUSIONS

Although ADI is known to cause less skin irritation than HW, nurses perceive ADI as more damaging, resulting in: (i) a low compliance with ADI and (ii) a higher prevalence of hand dermatitis because the more deleterious HW is preferred. This may result in an increase in occupational disease and nosocomial infections. Educational programmes should promote ADI as a procedure with good efficiency and skin tolerability to reduce the prevalence of hand eczema in nurses and to enhance compliance with hand hygiene standards.

Safety evaluation of topical applications of ethanol on the skin and inside the oral cavity

Ethanol is widely used in all kinds of products with direct exposure to the human skin (e.g. medicinal products like hand disinfectants in occupational settings, cosmetics like hairsprays or mouthwashes, pharmaceutical preparations, and many household products). Contradictory evidence about the safety of such topical applications of the alcohol can be found in the scientific literature, yet an up-to-date risk assessment of ethanol application on the skin and inside the oral cavity is currently lacking.The first and foremost concerns of topical ethanol applications for public health are its carcinogenic effects, as there is unambiguous evidence for the carcinogenicity of ethanol orally consumed in the form of alcoholic beverages. So far there is a lack of evidence to associate topical ethanol use with an increased risk of skin cancer. Limited and conflicting epidemiological evidence is available on the link between the use of ethanol in the oral cavity in the form of mouthwashes or mouthrinses and oral cancer. Some studies pointed to an increased risk of oral cancer due to locally produced acetaldehyde, operating via a similar mechanism to that found after alcoholic beverage ingestion.In addition, topically applied ethanol acts as a skin penetration enhancer and may facilitate the transdermal absorption of xenobiotics (e.g. carcinogenic contaminants in cosmetic formulations). Ethanol use is associated with skin irritation or contact dermatitis, especially in humans with an aldehyde dehydrogenase (ALDH) deficiency.After regular application of ethanol on the skin (e.g. in the form of hand disinfectants) relatively low but measurable blood concentrations of ethanol and its metabolite acetaldehyde may occur, which are, however, below acute toxic levels. Only in children, especially through lacerated skin, can percutaneous toxicity occur.As there might be industry bias in many studies about the safety of topical ethanol applications, as well as a general lack of scientific research on the long-term effects, there is a requirement for independent studies on this topic. The research focus should be set on the chronic toxic effects of ethanol and acetaldehyde at the point of impact, with special regard to children and individuals with genetic deficiencies in ethanol metabolism.

Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection

BACKGROUND

Recent data indicate that full efficacy of a hand rub preparation for hygienic hand disinfection can be achieved within 15 seconds (s). However, the efficacy test used for the European Norm (EN) 1500 samples only the fingertips. Therefore, we investigated hand coverage using sixteen different application variations. The hand rub was supplemented with a fluorescent dye, and hands were assessed under UV light by a blind test, before and after application. Fifteen non-healthcare workers were used as subjects for each application variation apart from one test which was done with a group of twenty healthcare workers. All tests apart from the reference procedure were performed using 3 mL of hand rub. The EN 1500 reference procedure, which consists of 6 specific rub-in steps performed twice with an aliquot of 3 ml each time, served as a control. In one part of this study, each of the six steps was performed from one to five times before proceeding to the next step. In another part of the study, the entire sequence of six steps was performed from one to five times. Finally, all subjects were instructed to cover both hands completely, irrespective of any specific steps ("responsible application"). Each rub-in technique was evaluated for untreated skin areas.

RESULTS

The reference procedure lasted on average 75 s and resulted in 53% of subjects with at least one untreated area on the hands. Five repetitions of the rub-in steps lasted on average 37 s with 67% of subjects having incompletely treated hands. One repetition lasted on average 17 s, and all subjects had at least one untreated area. Repeating the sequence of steps lasted longer, but did not yield a better result. "Responsible application" was quite fast, lasting 25 s among non-healthcare worker subjects and 28 s among healthcare workers. It was also effective, with 53% and 55% of hands being incompletely treated. New techniques were as fast and effective as "responsible application". Large untreated areas were found only with short applications. Fingertips and palms were often covered completely.

CONCLUSION

In clinical practice, hand disinfection is apparently better than practitioners of infection control often anticipate. Based on our data, a high-quality hygienic hand disinfection is not possible within 15 s. A 30 s application time can, however, be recommended for clinical practice. The currently recommended six steps of EN 1500 are not really suitable for clinical practice, because they yield comparably poor results. The most appropriate application procedure may be "responsible application", or one of the other new techniques.

Effects of disinfectants and detergents on skin irritation

We investigated the biological response of regular human skin to alcohol-based disinfectants and detergents in a repetitive test design. Using non-invasive diagnostic tools such as transepidermal water loss, laser-Doppler flowmetry and corneometry, we quantified the irritative effects of a propanol-based hand disinfectant (Sterillium), its propanol mixture (2-propanol 45% w/w and 1-propanol 30% w/w), sodium lauryl sulfate (SLS) 0.5% and distilled water. The substances were applied in a 2-D patch test in a repetitive occlusive test design to the back. Additionally, we performed a wash test on the forearms that was supposed to mimic the skin affection in the normal daily routine of health care workers. In this controlled half-side test design, we included the single application of the hand rub, SLS 0.5% and water as well as a tandem application of the same substances. Patch test and wash test showed similar results. The alcohol-based test preparations showed minimal irritation rather comparable to the application of water. However, the detergent SLS produced stronger barrier disruption, erythema and dryness than the alcohol-based preparations. There was no additional irritation at the combined use of SLS and disinfectants. By contrary, there was even a decrease in barrier disruption and erythema induced by the tandem application of SLS followed by alcohol-based disinfection compared with the use of SLS alone. These findings show a less irritant effect of alcohol-based disinfectants on the skin than detergents. Our study shows that there is no summation of irritating effects of a common detergent and propanol and that the combination of washing and disinfection has a rather protective aspect compared with washing alone.

Double-blind, randomized, crossover trial of 3 hand rub formulations: fast-track evaluation of tolerability and acceptability

OBJECTIVE

To compare healthcare workers' skin tolerance for and acceptance of 3 alcohol-based hand rub formulations.

DESIGN

Double-blind, randomized, crossover clinical trial.

SETTING

Intensive care unit in a university hospital.

PARTICIPANTS

Thirty-eight healthcare workers (HCWs).

INTERVENTION

A total of 3 alcohol-based hand rub formulations (hereafter, formulations A, B, and C) were used in random order for 3-5 consecutive working days during regular nursing shifts. Formulations A and B contained the same emollient, and formulations B and C contained the same alcohol at the same concentration. Use of each test formulation was separated by a "washout" period of at least 2 days. A visual assessment of skin integrity by a blinded observer using a standard 6-item scale was conducted before and after the use of each formulation. Univariate and multivariate analyses were used for the assessment of risk factors for skin alteration, and product acceptability was assessed by use of a customized questionnaire after the use of each formulation.

RESULTS

Thirty-eight HCWs used each of 3 formulations for a median of 3 days (range, 3-5 days). The mean amount of product used daily (+/-SD) was 54.9+/-23.5 mL (median, 50.9 mL). Both subjective and objective evaluation of skin conditions after use showed lower HCW tolerance for product C. Male sex (odds ratio [OR], 3.17 [95% confidence interval {CI}, 1.1-8.8]), fair or very fair skin (OR, 3.01 [95% CI, 1.1-7.9]), skin alteration before hand rub use (OR, 3.73 [95% CI, 1.7-8.1]), and use of formulation C (OR, 8.79 [95% CI, 2.7-28.4]) were independently associated with skin alteration.

CONCLUSIONS

This protocol permits a fast-track comparison of HCWs' skin tolerance for different alcohol-based hand rub formulations that are used in healthcare settings. The emollient in formulation C may account for its inferior performance.

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.

An in-use microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing

Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259+/-68 and 244+/-69min for groups S and R respectively (P=0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2h, 4h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2h and 4h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

Control and prevention of MRSA infections

Methicillin-resistant Staphylococcus aureus (MRSA) has posed an immense problem for clinicians in the hospital setting for years, emerging as the most frequent nosocomial infection. To deal with this problem pathogen and others, infectious disease specialists have developed a variety of procedures for their control and prevention, involving options from preventative measures such as decolonization and isolation of MRSA-confirmed patients, to the more simple procedures of hand washing, expanding glove use, and reducing time in the hospital. With the realization that MRSA is now a community problem, there are expanded efforts toward more direct intervention, such as the use of anti-MRSA antibacterials and vaccines, in an attempt to reduce the overall burden of MRSA.