Dermal tolerance and effect on skin hydration of a new ethanol-based hand gel

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.

Relationship between hand hygiene and cutaneous findings during COVID-19 pandemic

BACKGROUND

In the current situation of the COVID-19 pandemic, healthcare workers (HCWs) have to comply with hygiene conditions and use gloves more frequently and for a longer period of time than they would previously to avoid infection and prevent transmission.

AIMS

We aimed to characterize the adverse skin reactions occurring after hand hygiene and glove use in HCWs in a tertiary university hospital to determine the possible causative factors and whether the use of these measures is affected.

METHODS

Between April 15 and May 1, 2020, a cross-sectional survey was conducted, using online questionnaire, answered by HCWs in a tertiary university hospital.

RESULTS

The increase in general hand-skin problems during the pandemic period was statistically significant (P = .004). The most common symptom was dryness. During the pandemic period, 67 (24.3%) HCWs thought that the conditions were caused by glove use, and 197 (71.4%) thought that they were due to alcohol-based hand antiseptics. The incidence of other hand-skin conditions except for vesicles was statistically higher in women than in men (P < .001).

CONCLUSIONS

Increased number of hand-skin conditions during the pandemic should not be ignored, since hand hygiene and glove use are expected to increase.

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.

The effectiveness of alcohol-based gel for hand sanitising in infection control

This article aims to evaluate the evidence relating to the effectiveness of alcohol-based gel for hand sanitising, or 'handrub', in infection control in healthcare settings with particular reference to renal nursing, as this has become pertinent due to the increasing reliance on evidence-based practice. There is a need to implement better infection control strategies and education, to reinforce knowledge among the public, health professionals and those at high risk of infection not only in renal nursing, but also in other areas of practice. Healthcare-associated infections (HCAIs) put patients' safety at risk, increase morbidity and mortality, extend the length of hospital admission and increase the cost to the NHS. There is evidence that the prevalence of HCAIs in England can be minimised through the use of different infection control measures. For example, alcohol-based handrub has been found to be associated with minimising the spread of gastrointestinal infections not only in hospital settings, but also in childcare centres. In addition, the UK national guidelines recommend regular handwashing (implementing the right technique) when hands are visibly dirty and hand disinfection with alcohol-based handrub when they are not visibly dirty. This should be before, in between and after different healthcare activities are performed.

Comparison of hydroalcoholic rubbing and conventional chlorhexidine scrubbing for aseptic skin preparation in dogs

OBJECTIVE

To compare preparation time, ease of application, and elimination of skin contamination of 3 skin preparation methods for asepsis.

STUDY DESIGN

Experimental study.

ANIMALS

Healthy dogs (n = 6) with no clinical signs of skin disease.

METHODS

Three sites on each dog were randomly allocated to 1 of 3 preparation protocols for asepsis: (1) 5 scrubbings with chlorhexidine gluconate and rinsing (CHXG), (2) washing with mild soap prior to 3 rubbings with hydroalcoholic solution (soap-HAR), or (3) 3 rubbings with hydroalcoholic solution (HAR). The duration of each method of skin preparation was recorded. A Count-Tact agar plate was placed in the center of each site before, immediately after, 1 hour after, and 3 hours after antiseptic application. Plates were cultured, and colony forming units (CFU) were counted.

RESULTS

Skin preparation lasted an average of 375 seconds for CHXG, 240 seconds for soap-HAR, and 190 seconds for HAR (P = .00049). Nine CFU (median) were cultured from the skin prior to preparation, with no difference between sites on any animal or for any method. Colony forming units were not detected at any time on any site in any dog after antiseptic application.

CONCLUSION

Rubbing with hydroalcoholic (HA) solution was as effective as CHXG and prevented bacterial growth for at least 3 hours under these experimental conditions. Rubbing with hydroalcoholic solution was also faster and easier to perform.

CLINICAL SIGNIFICANCE

Because there is currently no known resistance to HA solution, preparation of the surgical site with HAR should be considered to prevent the emergence of bacterial resistance to chlorhexidine as well as potential cross-resistances to antibiotics. Transfer to clinical animals requires additional investigation.

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.

Surgical Hand Antisepsis With Alcohol-Based Hand Rub Comparison of Effectiveness After 1.5 and 3 Minutes of Application

Objective.

Research has shown 1.5 minutes of surgical hand antisepsis with alcohol-based hand rub to be at least as effective under experimental conditions as the 3-minute reference disinfection recommended by European Norm 12791. The aim of the present study was to validate the effectiveness of 1.5 minutes of surgical hand antisepsis in a clinical setting by comparing the effectiveness of 1.5- and 3-minute applications of alcohol-based hand rub (45% vol/vol 2-propanol, 30% vol/vol 1-propanol, and 0.2% mecetronium ethylsulphate).

Design.

Prospective crossover trial in which each surgeon served as his or her own control, with individual randomization to the 1.5-or the 3-minute group during the first part of the trial.

Setting.

Basel University Hospital, Switzerland.

Participants.

Thirty-two surgeons with different levels of postdoctoral training.

Methods.

We measured the bactericidal effectiveness of 1.5 minutes and 3 minutes of surgical hand antisepsis with alcohol-based hand rub by assessing the mean (± SD) log10 number of colony-forming units before the application of hand rub (baseline), after the application of hand rub (immediate effect), and after surgery (sustained effect) so as to follow European Norm 12791 as closely as possible.

Results.

The immediate mean (± SD) log10 reduction in colony-forming units (cfu) was 2.66 ±1.13 log10 cfu for the 1.5-minute group and 3.01 ±1.06 log10 cfu for the 3-minute group (P = .204). Similarly, there was no statistically significant difference between the 2 groups with respect to the sustained effect; the mean ( ± SD) log10 increase in bacterial density during surgery was 1.08 ± 1.13 log10 cfu for the 1.5-minute group and 0.95 ± 1.27 log10 cfu for the 3-minute group (P = .708). No adverse effects were recorded.

Conclusion.

In this clinical trial, surgical hand antisepsis with alcohol-based hand rub resulted in a similar bacterial reduction, regardless of whether it was applied for 3 or 1.5 minutes, which confirms experimental data generated with healthy volunteers.

Population Kinetics of the Skin Flora on Gloved Hands Following Surgical Hand Disinfection With 3 Propanol-Based Hand Rubs: A Prospective, Randomized, Double-Blind Trial

Objective.

To study the bacterial population kinetics on gloved hands following hand treatment with 3 optically indistinguishable, alcohol-based surgical hand rubs, with and without supplements to delay bacterial regrowth.

Design.

Prospective, randomized, double-blind, balanced quasi-Greco-Latin square design.

Setting.

Microbiology laboratory of the Medical University Vienna, Austria.

Participants.

Twenty-four healthy adult volunteers without skin lesions.

Surgical Hand Rubs.

The following hand rubs, all stained blue, were applied to the hands for 3 minutes: 1-propanol 60% vol/vol (A); 2-propanol 70% m/m plus chlorhexidine gluconate 0.5% wt/wt (B); 2-propanol 45% wt/wt plus 1-propanol 30% wt/wt plus mecetronium etilsulfate 0.2% wt/wt (C). As a reference formulation (R), 1-propanol 60% vol/vol, unstained, was applied for the same amount of time.

Method.

In 8 once-weekly tests, 24 subjects randomly assigned to use the 4 hand rubs in groups of 6 persons each performed hand hygiene according to the method described in European Norm 12791. Every subject used one preparation at a time, the antimicrobial effect of which was evaluated at 2 sampling times. After week 8, each volunteer had tested every preparation at every preset sampling time. All preparations were tested in parallel.

Results.

The mean pretreatment counts of viable bacteria (in colony-forming units per milliliter) in fluid samples were not significantly different between week 1 and week 8, nor between the right and left hands (analysis of variance [ANOVA], P > .1). Immediately after applying the formulation (t0), bactericidal effects of the blinded formulations A and C were equivalent to that of the reference formulation R, whereas the effect of B was questionable. The population kinetics of the flora on the hands proceeded from large and fast initial reductions of the skin flora by 2.7 log units (A), 3.1 log units (B), 3.3 log units (reference formulation), and 3.5 log units (C), to slow regrowth. However, even after 6 hours wearing gloves viable bacterial counts remained significantly (P < .01) below the baseline values (by 0.9 log [reference formulation], 1.1 log [A and B], and 1.5 log [C]). The slowest regrowth 1 and 3 hours after application (∆ from t0, 0.1 log and 0.7 log respectively) was seen with formulation C, and the slowest regrowth after 6 hours was seen with formulation B (∆ from t0, 1.6 log). These differences did, however, not reach statistical significance.

Conclusions.

With respect to the rapid and dramatic antibacterial action of suitable alcohols at high concentrations and with appropriate neutralizers, the contribution of supplements to the delay of bacterial regrowth on gloved hands appears rather minor, if a product only exerts an immediate effect equivalent to that of the reference disinfection procedure described in EN 12791.

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.

Comparison of the antibacterial efficacy and acceptability of an alcohol-based hand rinse with two alcohol-based hand gels during routine patient care

The aims of this study were to compare the antibacterial efficacy of handrubbing with an alcoholic rinse (AHRR) and two different alcoholic gels (AHRG) in reducing hand contamination under practical use conditions. We wanted to assess the acceptability of the three products and to determine the effect of each product on overall hand hygiene compliance. A prospective alternating time-series clinical trial was performed in a medical intensive care unit. The study was divided into three six-week periods (P1, P2, P3). Handrubbing was achieved with Sterillium rinse (AHRR) during P1, sterillium gel(AHRG-1) during P2 and Manugel Plus (AHRG-2) during P3. Pre- and post-rubbing hand contaminations were assessed immediately after a direct contact with a patient, using the glove juice technique. Health care workers (HCWs) evaluated the acceptability of the products through a self-administered anonymous questionnaire. Compliance of HCWs with hand hygiene was assessed during the three periods. We studied 242 handrubbing opportunities. The mean reduction factor (expressed as the Log(10) CFU/mL) of the AHRR, AHRG-1 and AHRG-2 were 1.28+/-0.95, 1.29+/-0.84 and 0.51+/-0.73, respectively (p<0.001). Assessment of the three products by HCWs indicated that AHRR and AHRG-1 were significantly better accepted than AHRG-2. The overall compliance of HCWs to hand hygiene was better when gel was available. Under practical use conditions, AHRG-1 and AHRR were more effective than AHRG-2, although all were claimed to pass the European standard EN1500. In vivo trials are essential to compare the antimicrobial efficacy of products for handrubbing.

Safety, Acceptability, and Tolerability of 3 Topical Microbicides Among Heterosexual Kenyan Men

OBJECTIVES

To compare the acceptability, tolerability, and safety of 3 topical microbicide formulations (62% ethyl alcohol in emollient gel and 0.1% and 0.4% benzalkonium chloride on a sanitary wipe) for use on male genitalia.

DESIGN

This triple-randomized crossover study among men attending a sexually transmitted disease (STD) clinic in Nairobi, Kenya assigned individuals without clinical evidence of an STD to apply products to the penis in a predetermined random order, each for a 2-week period with a 1-week washout period between each product. Men recorded side effects and were examined for adverse events.

RESULTS

Of 39 participants, 33 (84%) completed 6 clinic visits plus 3 home visits by community health workers. Participants reported use of 62% ethanol gel and 0.1% and 0.4% benzalkonium on 99%, 99%, and 96% of daily scheduled applications; 99%, 98%, and 97% of preintercourse applications, and 99%, 94%, and 98% of postintercourse applications. All participants said they would recommend all 3 products to a friend; 72% preferred the 62% ethanol gel, 17% the 0.1% benzalkonium, and 11% the 0.4% benzalkonium. One person developed objective signs of a genital ulcer after 14 days of 0.4% benzalkonium wipe use.

CONCLUSIONS

Two of the 3 topical microbicides had minimal reported adverse effects, and no adverse effects were observed during use of the ethanol gel, which was preferred by most men.

Assessment of effects of an additional dietary natural mineral water uptake on skin hydration in healthy subjects by dynamic barrier function measurements and clinic scoring

BACKGROUND/AIMS

The skin protects the body's organs and tissues from damage and physical, chemical and bacteriological injuries. It also prevents the transcutaneous loss of water. The present study was conducted to assess the effects of additional dietary natural mineral water uptake on skin hydration and cutaneous well-being in subjects with dry skin.

METHODS

Eighty subjects (44 women and 36 males, mean age 56+/-5.6 years) were included in the study, randomised per forearm and stratified by gender. Skin surface hydration, transepidermal water loss (TEWL), sorption-desorption test, skin colour, thickness and micro-relief were evaluated on the forearms. Clinical scoring of dryness, roughness and elasticity was performed by a dermatologist.

RESULTS

An improvement of skin hydration was observed after additional water uptake, statistically modifying the hydration level as well as TEWL, the water-binding capacity of the uppermost layers of the stratum corneum. Improvements of softness, smoothness and skin-moisturising effect were perceived by healthy subjects, and skin micro-relief was improved.

CONCLUSION

We suggest that natural mineral water supplementation may be used in order to improve the hydration of skin dryness as a complementary cosmetic approach.

Skin reactions related to hand hygiene and selection of hand hygiene products

BACKGROUND

In October 2004, The World Health Organization (WHO) launched the World Alliance for Patient Safety. Within the alliance, the first priority of the Global Patient Safety Challenge is to reduce health care-associated infection. A key action within the challenge is to promote hand hygiene in health care globally as well as at the country level through the campaign "Clean Care is Safer Care." As a result, the WHO is developing Guidelines on Hand Hygiene in Health Care, designed to be applicable throughout the world.

METHODS

This paper summarizes one component of the global WHO guidelines related to the impact of hand hygiene on the skin of health care personnel, including a discussion of types of skin reactions associated with hand hygiene, methods to reduce adverse reactions, and factors to consider when selecting hand hygiene products.

RESULTS

Health care professionals have a higher prevalence of skin irritation than seen in the general population because of the necessity for frequent hand hygiene during patient care.

CONCLUSION

Ways to minimize adverse effects of hand hygiene include selecting less irritating products, using skin moisturizers, and modifying certain hand hygiene practices such as unnecessary washing. Institutions need to consider several factors when selecting hand hygiene products: dermal tolerance and aesthetic preferences of users as well as practical considerations such as convenience, storage, and costs.

Skin condition associated with intensive use of alcoholic gels for hand disinfection: a combination of biophysical and sensorial data

Although hand hygiene is an important and inexpensive measure to prevent nosocomial infections in clinical settings, the compliance of healthcare workers remains low. In Europe, alcoholic hand disinfection is first choice, but there exists a limited user acceptability due to estimated adverse effects on skin condition. This study was designed to investigate skin tolerance to alcohol-based disinfecting gels and changes in skin condition depending on humectant concentration, alcohol grades, as well as type of alcohol used. A comparison of 6 alcohol-based gels was made based on a randomized double-blind study under in use conditions for 1 day. Skin condition was evaluated by measuring transepidermal water loss (TEWL), stratum corneum hydration, apparent skin pH, redness and degree of scaliness. With respect to user acceptability, all gels were sensorially evaluated using a questionnaire. We saw that none of the alcohol-based gels, applied under in use conditions, altered TEWL or caused irritation. All gels hydrated the skin, proportionally to their glycerine content, and decreased skin pH. Elevated ethanol concentrations resulted in increased scaliness. Sensorial assessment revealed less appreciation for isopropanol. From this study, it was concluded that gels containing an elevated glycerine concentration and 70% (v/v) ethanol are preferred.

Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs

Tests were performed under working practice conditions to measure the tolerance and acceptability of commercially available hand rubs with proven efficacy. The products were compared with those in current use at the Hospices Civils de Lyon for surgical hand disinfection (Sterillium) and hygienic hand disinfection (Purell) to obtain information for public sector purchases. The 12 test products were Alcogel H, Assanis Pro, Clinogel, Dermalcool, Manugel Plus, Manugel Plus NPC, Manurub Liquid, Manurub Gel, Purell 85, Spitacid, Spitagel and Sterillium Gel. They were tested from mid-November to mid-April over four periods of three weeks, separated by two-week intervals during which the customary product was re-introduced. Participation of hospital wards and theatres was voluntary. Skin dryness and irritation were scored before and after each test period. Acceptability and ease of use were assessed by means of a questionnaire. Among the eight surgical hand rubs, only Manurub Liquid, Manurub Gel and Manugel Plus NPC did not cause significantly more dryness and irritation than Sterillium. For the 10 hygienic hand rubs, differences were noted depending upon the test period. Overall, Assanis Pro, Clinogel, Purell 85 and Sterillium Gel did not cause significantly more dryness and irritation than Purell. However, over the (colder) first three test periods, Assanis Pro and Sterillium Gel caused more irritation and Purell 85 caused more dryness than Purell. Responses to the questionnaires on acceptability indicated that users preferred their customary hand rubs (Sterillium and Purell). As these field tests involving many participants did not identify any superior products, previous purchase orders were renewed.

Emollients in a propanol-based hand rub can significantly decrease irritant contact dermatitis

The objective of this study is to determine the effect of emollients in a propanol-based hand rub on skin dryness and erythema. In this prospective, randomized, controlled, double-blind trial, 35 subjects participated; of them approximately half were atopic (modified Erlanger atopy score > or =8). 2 propanol-based formulations were tested in a repeated open application test, 1 contained a mixture of emollients (0.81%, w/w). 2 aliquots of 0.7 ml of each formulation were applied twice per day over 2 weeks to the cubital fossa of each subject after random assignment of the preparations. Treatment areas were assessed before each application and 3 days postfinal application by visual inspection for erythema and dryness according to a standard scale. The sum score over all assessment time-points served as primary parameter. The mean sum score for erythema and dryness was significantly lower for the hand rub with emollients (0.8 +/- 2.4) in comparison with that for the hand rub without emollients (1.5 +/- 3.5; P = 0.022; Wilcoxon signed rank test). A comparison of the atopic and non-atopic subjects revealed no significant difference for any of the products (P > 0.05; Mann-Whitney U-test). It is concluded that the addition of emollients to a propanol-based hand rub can significantly decrease irritant contact dermatitis under frequent-use conditions.

Regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing

BACKGROUND

Aim of the study was to determine the effect of the regular use of a hand cream after washing hands on skin hydration and skin roughness.

METHODS

Twenty-five subjects washed hands and forearms with a neutral soap four times per day, for 2 minutes each time, for a total of two weeks. One part of them used a hand cream after each hand wash, the others did not (cross over design after a wash out period of two weeks). Skin roughness and skin hydration were determined on the forearms on days 2, 7, 9 and 14. For skin roughness, twelve silicon imprint per subject and time point were taken from the stratum corneum and assessed with a 3D skin analyzer for depth of the skin relief. For skin hydration, five measurements per subject and time point were taken with a corneometer.

RESULTS

Washing hands lead to a gradual increase of skin roughness from 100 (baseline) to a maximum of 108.5 after 9 days. Use of a hand cream after each hand wash entailed a decrease of skin roughness which the lowest means after 2 (94.5) and 14 days (94.8). Skin hydration was gradually decreased after washing hands from 79 (baseline) to 65.5 after 14 days. The hand wash, followed by use of a hand cream, still decreased skin hydration after 2 days (76.1). Over the next 12 days, however, skin hydration did not change significantly (75.6 after 14 days).

CONCLUSION

Repetitive and frequent hand washing increases skin dryness and roughness. Use of a hand cream immediately after each hand wash can confine both skin dryness and skin roughness. Regular use of skin care preparations should therefore help to prevent both dry and rough skin among healthcare workers in clinical practice.

In vitro activity of a novel compound, the metal ion chelating agent AQ+, against clinical isolates of Staphylococcus aureus

OBJECTIVES

To determine the efficacy of a novel antimicrobial compound, AQ+, against a genetically heterogeneous collection comprising 213 Staphylococcus aureus isolates from global sources. AQ+ is an aqueous preparation containing 0.5% 8-hydroxyquinoline.

METHODS

MICs were found for all the isolates tested using the BSAC microdilution method. Time-kill studies were performed according to NCCLS guidelines. Transmission electron microscopy (TEM) was used to view the ultrastructural effects of AQ+.

RESULTS

AQ+ was shown to strongly inhibit the growth of all isolates with a median MIC of 0.25% at a pH optimum of 9.2. Lowering the pH to 7.5 gave an approximately 4-fold reduction in efficacy and at pH 5.5 there was an approximately 8-fold reduction in efficacy. Methicillin-resistant S. aureus (MRSA) as well as vancomycin-intermediate S. aureus were shown to be as equally susceptible to AQ+ as methicillin-susceptible S. aureus. Time-kill curves for AQ+ were similar to those for gentamicin. TEM showed that AQ+ actively disrupts the cell wall of S. aureus leading to cell lysis.

CONCLUSIONS

These results suggest that AQ+ has strong antimicrobial activity and may be useful in preparations to reduce nasal and skin carriage of MRSA.

Surgical hand disinfection with a propanol-based hand rub: equivalence of shorter application times

The aim of this study was to determine the efficacy of a propanol-based hand rub at application times shorter than 3 min. The bacterial pre-value was obtained from the finger tips (prEN 12791). Subjects treated their hands with the reference procedure (n-propanol, 60%) for 3 min or the product (crossover design). Sterillium was applied for 3, 2, 1.5 and 1 min. Four other preparations were tested for 1 min. Post-values (immediate effect) were taken from one hand, and the other hand was gloved for 3h. After the gloves were removed, the second post-value was taken (sustained effect). Sterillium was more effective than the reference procedure at 3, 2 and 1.5 min (immediate and sustained effect). The immediate effect after 1 min was significantly lower [mean log(10) reduction factor (RF): 1.91+/-0.90 vs. 2.52+/-0.95; P=0.001], whereas the sustained effect was not (mean RF: 1.81+/-1.06 vs. 2.05+/-1.14; P=0.204). All other preparations failed the efficacy requirement at 1 min for both the immediate and sustained effect. Using 2 x 3 mL Sterillium for a total of 1.5 min for surgical hand disinfection was at least as effective as the 3-min reference disinfection.

Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit

This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.

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.

The six golden rules to improve compliance in hand hygiene

Improvement of compliance in hand hygiene is probably the most effective step in reducing the incidence of nosocomial infections (NI). But improvement of compliance is known to be complex. Six possibilities for improving compliance are available although some of them may be difficult to carry out. Rule 1: Select an alcohol-based hand rub which has a good skin tolerance and is acceptable to health care workers to use. This has been shown to improve compliance. Rule 2: The hand rub shall be easily available. Wall dispensers near the patient and pocket bottles may well help. Other possibilities should be assessed locally. Rule 3: Implement teaching and promotion of hand hygiene, which has been shown to be very effective. This is may be the most effective tool but will cost time and money. If money is a problem, rule 4 may be the solution. Rule 4: Create a hospital budget which covers all costs involved with preventable nosocomial infection. Combine it with the budget for hand hygiene products. Even a small number of prevented NI largely outweighs the cost of effective hand hygiene products. Rule 5: Get senior staff to set a good example in order to motivate junior staff, because negligence in hand hygiene appears to correlate with the number of professional years. Rule 6: Have the patient-staff ratio well balanced. It has been shown that staff shortage decreases hand hygiene compliance. Other factors may be important as well, but implementation of these 6 golden rules could be an effective step into the right direction.

Suitability of Sterillium Gel for surgical hand disinfection

In some countries, alcohol-based hand gels are used for hygienic hand disinfection but their efficacy and suitability for surgical hand disinfection has never been investigated. The efficacy of Sterillium Gel was investigated according to prEN 12791 in two separate experiments. Finger tips of 20 volunteers per experiment were sampled for resident skin bacteria before surgical hand disinfection. In a cross-over design, each volunteer carried out a surgical hand disinfection with the reference alcohol [n-propanol 60%, (v/v)] or Sterillium Gel [ethanol 85% (v/v)] for 3 min. After the product application, one hand was sampled for the immediate effect, the other hand was gloved for 3 h and then sampled for the sustained effect. Samples were analysed for remaining resident bacteria. The mean of the pre-value, the 0 h and 3 h values of the reference disinfection and the test product were calculated. With the reference alcohol, respective mean immediate log10-reduction factors of 2.06+/-0.76 and 2.23+/-1.13 were found in both experiments. The mean sustained effects with the reference alcohol were 2.03+/-1.14 and 1.44+/-0.81. Sterillium Gel achieved respective mean immediate effects of 2.48+/-1.06 and 2.13+/-0.81, the mean sustained effects were 2.77+/-0.95 and 2.18+/-0.72. They proved significantly larger than those obtained with the reference alcohol (P<0.05; pair-wise Wilcoxon test). Sterillium Gel, therefore, more than fulfils the efficacy requirements for surgical hand disinfection of prEN 12791. In addition, 25 of 26 operating theatre healthcare workers in an orthopaedic hospital found it suitable for surgical hand disinfection after a single use, which included putting on a pair of surgical gloves. Although none of them had ever used an alcohol-based gel before, they had rather been accustomed to alcohol-based liquid products for years. The main reasons given for the positive assessment were better skin feeling after use, smell and easier donning of the surgical gloves. No significant correlation was found between overall or dermal acceptance and years of professional experience, profession or number of gel portions used for surgical hand disinfection (Pearson's correlation; P>0.05).

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.

Spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent Sterillium Gel

The antimicrobial efficacy of alcohol-based hand gels has been shown to be significantly less than liquid hand rubs probably because of a lower concentration of alcohol. Sterillium Gel is the first hand gel with 85% ethanol. Its antimicrobial efficacy and user acceptability was studied. Bactericidal activity was tested according to prEN 12054 against Staphylococcus aureus, Enterococcus hirae, Pseudomonas aeruginosa and Escherichia coli (suspension test) and EN 1500 (15 volunteers; four replicates), fungicidal activity according to EN 1275 against Candida albicans and spores of Aspergillus niger (suspension test) and tuberculocidal activity against Mycobacterium terrae using the DGHM suspension test. Virucidal activity was determined in suspension tests based on reduction of infectivity with and without interfering substances (10% fetal calf serum; 0.3% erythrocytes and 0.3% bovine serum albumin). Ninety-six healthcare workers in hospitals in France and the UK used the gel for four weeks and assessed it by filling out a questionnaire. The gel was bactericidal (a reduction factor of > 10(5)-fold), tuberculocidal (reduction factor > 10(5)) and fungicidal (reduction factor > 10(4)) in 30 s. Irrespective of interfering substances the gel inactivated orthopoxvirus and herpes simplex virus type 1 and 2 in 15 s, adenovirus in 2 min, poliovirus in 3 min and papovavirus in 15 min by a factor of > 10(4)-fold. Rotavirus and human immunodeficiency virus were inactivated in 30 s (without interfering substances). Under practical use conditions it was as effective in 30 s as the reference alcohol in 60 s. Most users described the tackiness, aggregation, skin feeling after use and smell as positive or acceptable. A total of 65.6% assessed the new gel to be better than a comparator irrespective of its type (gel or liquid). Overall Sterillium Gel had a unique spectrum of antimicrobial activity. It is probably the first alcohol-based hand gel to pass EN 1500 in 30 s. Due to the excellent acceptance by healthcare workers it may significantly improve compliance for hand hygiene and thereby help to reduce the incidence of nosocomial infection.