Selection and evaluation for specific products

Alcohol-Based Hand Rub (AHR)

AHRs are the first choice for hand hygiene when hands are not visibly soiled and dirty. AHRs are less time consuming to use than washing with soap and water. The efficacy of the AHR depends on the quality of the product, the amount of product used, the time spent rubbing and the hand surface rubbed. Alcohols provide for a rapid kill of most transient microorganisms due to their ability to denature proteins. The most common types of alcohols used for hand hygiene include ethanol, isopropanol or combinations of these. The antimicrobial action of ethanol and isopropanol are similar. However, ethanol has greater activity against viruses than isopropanol. AHRs available for health care settings range in concentration from 60 to 90% alcohol. Concentrations higher than 90% are less effective because proteins are not denatured easily in the absence of water. Formulation can greatly influence the overall antimicrobial efficacy of AHRs and is a more important factor than alcohol concentration alone: indeed some commercial AHRs and WHO formulations failed to meet the US and European efficacy requirements and needed to be modified. Norovirus and other non-enveloped viruses (e.g., rotavirus, enterovirus) are a frequent cause of gastroenteritis outbreaks in health care facilities. Studies suggest that norovirus is inactivated by alcohol concentrations ranging from 70% to 90%. Since norovirus is a concern in all health care settings, this should be taken into consideration when choosing an AHR product. A minimum concentration of 70% alcohol should be chosen.

AHR Formulations and Product Selection

AHR products being considered for purchase must have proven microbicidal properties evaluated according to standard methods.

AHRs are available as rinses, gels and foams. The choice of product will depend on a number of factors (e.g., efficacy, safety, environmental concerns). Before selecting a product

a) form a point-of-care assessment team that includes representation from the infection control committee and front-line health care workers;

b) choose a product with proven efficacy according to the published literature;

c) verify local fire regulations regarding choice of AHR; some types of foam products are not permitted in health care facilities;

d) conduct a local risk assessment related to placement of AHR dispensers, taking into consideration the patient/HCW population, protrusion of dispensers in an unsafe manner, and product leakage on surfaces that could cause falls or surface damage;

e) identify locations which will provide the best access to AHR at point-of-care as well as workflow patterns; this might influence choice of product dispenser.

Sustained antimicrobial activity is not required or recommended for point-of-care products. The addition of other chemical agents to AHR formulations for non-surgical use is not necessary and may cause more hand irritation than the use of AHR alone.

Sustained antimicrobial activity is not required or recommended for point-of-care products. The addition of other chemical agents to AHR formulations for non-surgical use is not necessary and may cause more hand irritation than the use of AHR alone.

Risk of Fire Related to the Use of AHRs

The risk of fire related to the use of AHR is very small. Hands must be fully dry before touching the patient or their environment/equipment for the AHR to be effective and to eliminate the extremely rare risk of flammability in the presence of an oxygen-enriched environment or static electricity.

The placement and storage of AHR must be in compliance with fire prevention guidelines. AHR that is attached to the wall must not be installed within 150 mm. (six inches) of a source of ignition (i.e., electrical outlet, light switch); in addition, the wall space between the dispenser and the floor must remain clear and unobstructed; AHR that is placed on the bed itself should be secured in an approved holder made for this purpose; the product should be placed so that the spout faces outward from the bed to reduce the risk of excess alcohol dripping on the bed linen; AHR must not be installed near radiant heaters that can raise the temperature of the contents; AHR stock shall be located in a storage room protected with a 1-hour fire separation or in a fire safety cabinet.

Hand Washing Soaps

The physical actions of scrubbing with soap and water and rinsing are important for effective removal of material from the hands. It has been shown that at least 15 seconds of lathering with soap is required to remove transient flora.

Efficacy of Soaps

• Plain soaps act on hands by emulsifying dirt and organic substances (e.g., blood, mucous), which are then flushed away with rinsing. Antimicrobial agents in plain soaps are only present as a preservative.

• Antimicrobial soaps have residual antimicrobial activity and are not affected by the presence of organic material. Studies have shown that antimicrobial soap is more effective than plain soap and water in critical care settings such as intensive care units and burn units.

Since the advent of AHR, comparisons between AHR and antimicrobial soap have confirmed the superiority of AHR. The best evidence suggests that antimicrobial soap is equivalent to AHR in terms of microorganism reduction but is more aggressive on the hands and more time-consuming to use.

Where AHR is available at the point of care, antimicrobial soap is not required, including in critical care areas.

Disadvantages of antimicrobial soap include

a) antimicrobial soaps are harsher on hands than plain soaps and frequent use may result in skin breakdown; and

b) frequent use of antimicrobial soap may lead to disinfectant resistance.

Soap Formulations and Product Selection

Liquid and foam soaps may become contaminated. Liquid products must be dispensed in a disposable pump dispenser that is discarded when empty. They should never be “topped-up” or refilled. Bar soaps for hand hygiene must never be used in health care facilities except for the personal use of a single patient/resident. In this case, the soap should be supplied in small pieces that are designed for single-patient/ resident use, and the bar must be stored in a soap rack to allow drainage and drying. It should be discarded on patient/resident discharge. We don’t recommend their use ever other than in household situations.

Surgical Hand Preparation Products

A surgical hand preparation must eliminate the transient flora and reduce the resident flora of the hands. It should also inhibit growth of bacteria under the gloved hand. The spectrum of antimicrobial activity for a surgical hand preparation should be as broad as possible, so that it is active against bacteria and fungi.

Due to the rapid multiplication of bacteria under surgical gloves and the high percentage of glove punctures found after surgery, a hand hygiene product with a prolonged antiseptic effect on the skin is desirable.

In an operative setting, an AHR (surgical hand rub) or an antimicrobial soap (surgical hand scrub) with persistent antimicrobial activity should be used.

AHRs

Alcohols are effective for preoperative cleaning of the hands of surgical staff. Several AHRs have been licensed for use as a surgical hand rub and many formulations also contain long-acting compounds such as chlorhexidine gluconate. The antimicrobial activity of AHRs is superior to that of all other currently available methods of preoperative surgical hand preparation.

Non-alcohol-based Waterless Antiseptic Agents

At the present time, there is no evidence for the efficacy of non-alcoholic, waterless antiseptic agents in the health care environment. Non-alcoholic products invariably have a quaternary ammonium compound (QAC) as the active ingredient: these have not been shown to be as effective against most microorganisms as have AHR QACs are prone to contamination by Gram-negative organisms. QACs are also associated with an increase in skin irritancy. Non-alcohol-based waterless antiseptic agents are not recommended for hand hygiene in health care settings and should not be used.

- Link to IC/HH CC: 

References

• Best Practices for Hand Hygiene in All HealthCare Settings Available from http://www.publichealthontario.ca/en/eRepository/201012%20BP%20Hand%20Hygiene.pdf
• World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Health Care (May 2009).[Geneva, Switzerland]:[World Health Organization]; 2009. [cited June 24, 2009]; Available from: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf.
• Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 Suppl):S3-40
• Rotter ML European norms in hand hygiene Journal of Hospital Infection 2004;56, Supplement 2:6-9.
• Rotter M, Sattar S, Dharan S, Allegranzi B, Mathai E, Pittet D. Methods to evaluate the microbicidal activities of hand-rub and hand-wash agents. Journal of Hospital Infection, 2009;73: 191-199
• Widmer A.F., Rotter M., Voss A., Nthumba P., Allegranzi B., Boyce J., Pittet D. Surgical hand preparation: state-of-the-art. Journal of Hospital Infection, 2010; 74: 112-122.
• Girard R., Bousquet E., Carré E., Bert C., Coyault C., Coudrais S., Regard A., Laprugne Garcia E., Valdeyron M.L., Pergay V. Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs. Journal of Hospital Infection. 2006; 63: 281-288.
• Edmonds SL, Macinga DR, Mays-Suko P, Duley C, Rutter J, Jarvis WR, Arbogast JW Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs: formulation matters. Am J Infect Control. 2012;40:521-525

FEM Contributors

• Vladimir Prikazsky
• Gaetano Privitera