Medicine Update (2003): 11(4), 41-44

Modest measure with phenomenal effects: Alcohol based hand sanitizers

Mahender Nayak, M.B.B.S., Senior Executive
and
Kala Suhas Kulkarni, M.D., Medical Advisor
R&D Center, The Himalaya Drug Company, Makali, Bangalore, India.

THE HARSH REALITY

Nosocomial infections, many of which are transmitted from patient to patient by poorly
sanitized hands of health care workers, exert a significant toll in human and economic terms
every year1-4. Even though good hand hygiene is acknowledged as a simple but powerful
technique for preventing nosocomial infections, these infections remain a major problem5.
The infections are commonly caused by organisms such as antibiotic-resistant gram-negative
bacilli, gram-positive staphylococci, enterococci, and Candida species. These organisms are
reported to affect an average of 7% to 10% of patients admitted to hospitals and up to 30% of
critically ill patients6. The rate of these infections per 1000 patient days has risen by 36%
climbing from 7.2 in 1975 to 9.8 in 19957.
THE BARRIERS
Hand hygiene has always been considered one of the cornerstones of infection control but
adherence to recommendations for hand-hygiene practices remains extremely low in most
health-care settings8. Compliance with handwashing in hospital environments is generally
less than 50%9. Large number of barriers to appropriate hand hygiene have been reported10-12.
Careful epidemiological investigations have clearly identified some of the key parameters
involved and have proposed corrective measures. Unsurprisingly, the leading factor for noncompliance is time constraint. Other reasons reported by Health Care Workers for the lack of
adherence with hand hygiene recommendations include: skin irritation by hand hygiene
agents, inaccessibility of hand hygiene supplies, interference with Health Care Workerspatient relationship, patient needs perceived as a priority, wearing of gloves, forgetfulness,
the lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and
understaffing, and the lack of scientific information showing a definitive impact of improved
hand hygiene on hospital-acquired infection rates.
THE HAND HYGIENE ETIQUETTES
Two major types of microorganisms may be found on the skin: organisms that reside on it
(resident flora) and transient or contaminant flora13. Unless introduced into the body by
trauma or invasive devices, the pathogenic potential of the resident flora (coagulase-negative
staphylococci, Corynebacterium species, Micrococcus species) is considered low. In contrast,
transient flora (typically Escherichia coli, Pseudomonas aeruginosa) cause most nosocomial
infections resulting from cross-transmission, but they are easily removed by handwashing14.

Hand hygiene can be achieved through either handwashing or hand disinfection.

Handwashing refers to the action of washing hands with an unmedicated detergent and water,
or water alone, to remove dirt and loose transient flora to prevent cross-transmission15.
Hygienic handwashing refers to the same procedure with the addition of an antiseptic agent.
Hand disinfection refers to any action in which an antiseptic solution, either medicated soap
or alcohol, is used to clean hands. Some experts refer to the use of detergent-based antiseptics
or alcohol as "degerming."
Handrub consists of rubbing hands with a small quantity of a highly effective and fast-acting
antiseptic agent. Because alcohols have excellent activity and the most rapid bactericidal
action of all antiseptics, they are the preferred agents for hygienic handrubs. Other antiseptics
include iodophores, chlorhexidine gluconate, triclosan, phenol derivatives, and quaternary
ammonium compounds. The objective of hand hygiene is to decrease hand colonization with
transient flora. To have a high impact, the ideal technique should be quick to perform, reduce
hand contamination to the lowest possible level, and be free from deleterious side effects like
dryness, cracks, irritant dermatitis.
THE GUIDELINES
The CDC/HICPAC system for
Guidelines for hand hygiene in health-care settings categorising recommendations is as
have been revisited recently by an international group follows:
IA = Strongly recommended for
from the US Centers for Disease Control and
implementation and strongly
Prevention (CDC) Healthcare Infection Control
supported by well-designed
experimental,
clinical,
or
Practices Advisory Committee (HICPAC), the Society
epidemiological studies;
for Healthcare Epidemiology of America (SHEA), the IB = Strongly recommended for
implementation and supported
Association for Professionals in Infection Control and
by some experimental, clinical,
Epidemiology (APIC), and the Infectious Diseases
or epidemiological studies and
Society of America (IDSA) who conducted a thorough
a strong theoretical rationale;
IC
=
Required for implementation,
review of published evidence dealing with hand
as mandated by federal and/or
16
hygiene . Recommended indications for hand hygiene
state regulation or standard;
during patient care, classified according to their level of II = Suggested for implementation
and supported by suggestive
evidence, given below17-19.
clinical or epidemiological
A: Wash hands with a non-antimicrobial soap and
studies
or
a
theoretical
rationale;
water or an antimicrobial soap and water when
No
RECOMMENDATION
=
hands are visibly soiled or contaminated with
Unresolved issue (practices for
which insufficient evidence or
proteinaceous material. (IA)
no consensus regarding efficacy
B: If hands are not visibly soiled, use an alcoholexist).
based handrub for routinely decontaminating
hands in all other clinical situations described in items listed below. (IA)
Before having direct contact with patients (IB)
Before donning sterile gloves when inserting a central intravascular catheter (IB)
Before inserting indwelling urinary catheters, peripheral venous cathethers, or other
invasive devices that do not require a surgical procedure (IB)

C:

After contact with a patient's intact skin (as in taking a pulse or blood pressure, or
lifting a patient) (IB)
After contact with body fluids or excretions, mucous membranes, non-intact skin, or
wound dressings, as long as hands are not visibly soiled (IA)
If moving from a contaminated-body site to a clean-body site during patient care (II)
After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient (II)
After removing gloves (IB)
Wash hands with antimicrobial/non-antimicrobial soap and water if exposure to
Bacillus anthracis is suspected or proven. The physical action of washing and rinsing
hands under such circumstances is recommended because all hand antiseptics have poor
activity against spores.

The new guideline recommend that when hands are visibly soiled with blood or other body
fluids, or contaminated with proteinaceous material, hands should be washed with either nonantimicrobial soap and water or antimicrobial soap and water. However, the most
revolutionary recommendation concerns the use of alcohol-based handrub formulations as the
new standard of care, thus requiring a system change that must be addressed in most
hospitals.
Easy, immediate access to hand-hygiene facilities and agents and rapid antimicrobial action
are key elements to improve compliance, and should be achievable in all health-care settings.
Bedside handrubbing requires only 20 seconds, thus bypassing the time constraint factor20.
Promoting alcohol-based handrubs was recommended because they require less time to use,
are more effective, and are less irritating to skin than traditional handwashing21. Importantly,
hand cleansing is required regardless of whether gloves are used or changed22.
Failure to remove gloves after patient contact or between dirty and clean-body-site care on
the same patient has to be regarded as non-compliance with recommendations. Furthermore,
it is not appropriate to wash and reuse gloves between patient contact and hand hygiene is
recommended after glove removal. Several reports have stressed the risk that staff may move
from patient to patient without glove change, resulting in the subsequent cross-transmission
of nosocomial pathogens. Recommendations are:
(1) Wear gloves when contact with blood, body fluids, or other potentially infectious
materials, mucous membranes, and non-intact skin can be reasonably anticipated;
(2) Remove gloves after caring for a patient;
(3) Do not wear the same gloves for the care of more than one patient;
(4) Do not wash gloves between patients; and (5) change gloves during patient care if
moving from a contaminated body site to a clean site.
ADVANTAGE OF ALCOHOL HAND RUBS
Appropriate compliance to hand hygiene depends, among other factors, on the possible side
effects of the agent. Hand cleansing can increase skin pH, reduce lipid content, increase

transepidermal water loss, and even increase microbial shedding. Alcohol-based solutions
(isopropanol, ethanor or n-propanol, in 60%-90% vol/vol) are less irritating to skin than is
any antiseptic or nonantiseptic detergent. Health Care Workers with damaged skin are likely
to be less compliant with hand hygiene recommendations. Removal of transient flora by the
agent also is less effective on damaged skin23.
This problem can be overcome by the adjunction of emollients or moisturizers to the handrub
solution to prevent dehydration of the skin, loss of lipids, or excessive desquamation.
Alcohols with the addition of emollients are at least as tolerable and efficacious as are
detergents and probably protect against cross-infection by keeping the resident skin flora
intact. In a comparative study between alcohol-based hand gel and soap and water, it was
seen that the latter increased dryness and irritation of the skin compared with the handrub24.
Another prospective, randomized study concluded that in a neonatal intensive care unit
(NICU) where frequent hand hygiene was required, cleaning hands with mild soap and
degerming thereafter with an alcohol-based product was an acceptable alternative to the
traditional antiseptic handwash and reduced damage to the skin of HCWs25.
CONCLUSION
Knowledge about hand hygiene, awareness of personal handwashing practices, types of hand
hygiene products, and accessibility of supplies have all been recognized as factors that may
influence Health Care Workers adherence to hand hygiene recommendations. Education and
training, the most frequently implemented interventions designed to improve adherence, have
had limited long-term success26,27. Interventions focused on the organizational level have
shown some evidence of improving adherence28. Yet being too busy is often cited as an
explanation for not practicing recommended hand hygiene, even though prevention of patient
infections is recognized as the most important reason for adherence29,30. Strategies to improve
hand-hygiene compliance must be multifaceted and include staff education and motivation,
the use of performance indicators, and hospital management support28,31.
Education is a vital component and must be promoted at all levels of experiencedoctors
included. Educational programmes need to address issues such as availability and awareness
of guidelines for hand hygiene, potential risks of transmission of microorganisms to patients
as well as potential risks of staff colonisation or infection acquired from the patient,
knowledge about indications for hand hygiene during daily patient care, awareness of the
very low average compliance with hand-hygiene practices of most health-care workers, and
recognition of opportunities for hand hygiene associated with high risk for crosstransmission32.
Coaching should also focus on the relative efficacy of the different hand-hygiene agents
available and on the appropriateness, efficacy, and understanding of the use of hand hygiene
and skin-care protection agents23,24.

Techniques for hand hygiene should be taught, and include the amount of hand-hygiene
solution to use, duration of procedure, and reasons for the institutional choice of handhygiene agents. Teaching must include a discussion of the morbidity, mortality, and costs
associated with cross-infections, and emphasise the epidemiological evidence for the
definitive effect of improved hand hygiene on nosocomial infection and resistant-organism
transmission rates. Finally, hand-hygiene promotion education should consider active
participation at individual and institutional level, as well as enforcement of individual and
institutional self-efficacy33. Monitoring of compliance by ward staff as well as the amount of
alcohol-based handrub used are key indicators to measure staff adherence and improvement
with hand-hygiene recommendations. Performance feedback is strongly recommended.
Behavioural theories and reported experiences, suggest that multifaceted interventions have
more chance of success than single actions or promotion programmes that focus on one or
two elements only. These strategies have similarities with principles of societal marketing
methods. However, further studies are needed to assess the key determinants of hand-hygiene
behaviour and promotion among different caregiver populations, to develop methods to
secure senior management support, and to implement and evaluate the impact of the different
components of multifaceted promotion programmes34,35.
Some of these targets are clearly related to the institution and would require senior
management support and commitment to be effective. Improving hand-hygiene practices can
reduce cross-transmission and the spread of antimicrobial resistance36. Most importantly,
successful hand-hygiene promotion campaigns will improve patient safety and quality of
care.
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