Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial

BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7360.362 (Published 17 August 2002)
Cite this as: BMJ 2002;325:362

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Displaying 1-10 out of 15 published

13 December 2006

I know it's three years since this was posted, but I've only just come across it and had to respond to this particular post. I have had a professional interest in the subject of latex allergy and have performed countless literature reviews over the past ten years, in order to increase my own knowledge. The use of powdered latex gloves has been linked to the increased incidence of latex allergies, following the increase in Human Immunovirus (HIV) / Auto-immune Deficiency (AIDS) cases in the mid-1980s. Medical companies who were not already producing gloves, jumped on the 'glove band -wagon', the result of which was production, distribution and use of a vast amount of poor quality, powdered latex gloves, which have since been deemed as a major health hazard. The reason is as follows: the powder acts as an abrasive agent, causing micro-abrasions on the hands of the wearer; the latex proteins adhere to this powder and enter the wearer's system through these abrasions, exposing the wearer to increased levels of latex proteins. The wearer is then at risk of developing a latex allergy - it must be noted however, that not everyone who wears latex gloves will develop a latex allergy. And not all latex allergy sufferers will have an anaphylactic reaction. However, this cannot be guaranteed, therefore patients / healthcare staff with a latex allergy should not be exposed to any latex products within the healthcare setting. A couple of years ago a nurse in England received a six-figure sum from her NHS Trust because they did not provide a safe, latex-free environment for her to work in. Various organisations, such as the Food and Drug Agency (FDA) and the Medical Devices Agency (MDA)have all produced hazard notices regarding powdered latex gloves. There are now strict criteria that every manufacturer of latex gloves must adhere to, such as reducing the extractable latex proteins to below 50mcgs, etc. The Health and Safety Executive (HSE) in the United Kingdom has a policy which states that should latex gloves be used, they must be of the powder- free variety. Many healthcare establishments have switched to non-latex gloves for this reason. Unfortunately, until there is a world-wide ban on powdered latex gloves, they will still continue to be produced, as they are usually cheaper than the non-powdered variety. Alcohol hand-rubs are not a cause of latex allergies, although alcohol hand-gels should be checked for latex content.

For the record, I use the alcohol hand-rub (Sterillium) cited in the article to 'scrub-up' with, as Chlorhexidine, Triclosan and Iodine-based solutions cause a dermatitis reaction for me. As Sterillium contains an emollient, I do not have any problems with it. It also reduces the risk of poor technique often seen when washing with antiseptic soap and water (the latter of which is not sterile anyway!)

Interesting debates here...!

Fiona Couper

Competing interests: None declared

Competing interests: None declared

Fiona M Couper, Operating Theatre Team Leader

Golden Jubilee National Hospital, G81 4HX

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7 January 2003

Editor,

The response from Chris Chung[What about gloves? 5 January 2003] deserves further consideration.

I am personally acquainted with nurses who have allergies caused by the use of latex gloves while working in hospitals. Many nurses and doctors are simply not aware of the danger.

Some nurses are now coming to work with a self-injection system of adrenaline in their kit, because they have had their first serious anaphylactic event.

The high use of gloves seemed to start back in the mid-1980's, when something called HTLV-III was all the rage.

I personally use nitrile gloves which are latex free, though these too may cause problems eventually.

Phillip Colquitt
Independent Technical Advisor.

Competing interests:   None declared

Competing interests: None declared

Phillip J. Colquitt, Technical Advisor

Independent

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5 January 2003

I have taught to wear gloves in addition to handwashing where possible.

It would be interesting to compare bacterial contamination rates of patients and equipment between those that wash their hands and those that wash their hands and wear gloves.

Competing interests:   None declared

Competing interests: None declared

Chris Chung, SHO

ROYAL HOSPITAL FOR SICK CHILDREN, GLASGOW

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EDITOR - We welcome the work of Girou and colleagues regarding the key infection control activity of hand decontamination (1). Based, however, on the information that is made available about their study, we have some concerns about its validity.

Firstly, we feel that a fair comparison of the two methods has not been made. While all participants had been instructed prior to the trial in the use of handrub, no similar instruction had been provided for handwashing. As the authors point out, the superior effectiveness of handrubbing is due in part to the inadequate time spent on handwashing. This is not surprising given the difference in instruction that participants had received, which therefore represents a source of potentially major bias.

Secondly, we are unclear about some of the study details. The description of the method does not enable the reader to confidently identify the precise points in the hand hygiene/patient care process when sampling took place, nor does it give the rationale for susceptibility testing of isolates. That the latter was performed is mentioned, but the results are not then presented or discussed.

While stating that the Mann Whitney test was used to compare percentage reduction of hand contamination between the two groups, details of this are not presented and it is not clear how data have been analysed. This is reflected in the apparent discrepancy between the data presented in the rather confusing figure 2 and the data in table 2. The former suggests a median percentage reduction in colony count of 83% for handrubbing and 58% for handwashing, while the latter quotes figures of 86% and 73% respectively.

Finally there are some inconsistencies in the terminology, which need to be clarified. This seems to us to be a pragmatic study, performed in the field, which is estimating the effectiveness and not the efficacy of the hand hygiene methods that are being compared. The reference to efficiency in the abstract conclusion has no obvious relevance to the study.

Given the commendable aim of Girou and colleagues to add to the scant evidence base regarding the relative effectiveness of hand decontamination agents (2) we feel that clarification of this potentially important study is desirable. In the longer term, further research is needed into health professionals’ attitudes towards hand hygiene, into the side-effects of frequent, long-term use of handrubs and soaps and into the relative impact on ward routine of the two methods. Only then can an informed decision be made regarding the overall relative merits of the two methods examined in this study.

Marko Petrovic Locum Consultant in Communicable Disease Control

Allan Silverwood Senior Nurse Specialist in Health Protection/Infection Control

With thanks to our colleagues in the Greater Manchester Health Protection Unit for their contribution

Greater Manchester Health Protection Unit Floor 7B, Peel House Albert Street Ecccles Manchester, M30 0NJ e-mail: marko.petrovic@gmhpu.nhs.uk

1. Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of handrubbing with alcohol vased solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362 at: http://bmj.com/cgi/content/full/325/7360/362

2. http://www.epic.tvu.ac.uk/PDFFiles/Standard%20Principles%20Tech%20Report...

Competing interests: None declared

Marko Petrovic, Locum Consultant in Communicable Disease Control

Allan Silverwood

Greater Manchester Health Protection Unit, Floor 7B, Peel House, Eccles, Manchester M30 0NJ

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Editor We were interested to note the findings of Girou et al who demonstrated that during routine patient care, handrubbing with an alcohol based solution is significantly more efficient in reducing hand contamination than handwashing with antiseptic soap.1

We conducted an analogous study recently, which looked at the 'in use' efficacy of an alcohol handrub (70% ethanol, carbomer, isopropyl myristate, glycerine, monopropylene glycol, vitamin E and demineralised water; ‘Guest Medical’, Kent, UK) in eliminating methicillin resistant Staphylococcus aureus (MRSA) from the fingertips of hospital staff.

The study was conducted within a large District General Hospital in North London in December 2001. A total of 110 healthcare staff including doctors, nurses, occupational therapists, healthcare support workers, administrators and porters were approached at random within their area of work on a single day and invited to take part anonymously. There was no prior knowledge of the study.

Each member of staff was asked to place prints of their dominant thumb, index finger and middle finger onto a plate of ‘Baird Parker’ agar (selective for Staphylococcus aureus). Two 'squirts' (total ~0.5mls) from a 50ml ‘pocket-size’ dispenser of the alcohol hand rub were then sprayed onto their hands and they were asked to apply this as they would normally – with no extra instruction. After allowing the alcohol to dry fully, fingerprints were taken again in the same way with a fresh agar plate.

Plates were incubated at 370C for 48 hours. Typical colonies were confirmed as Staphylococcus aureus and checked for methicillin sensitivity in the normal way. ‘Before’ and ‘after’ results revealed that prior to application of the hand rub, a total of 25 / 110 (22.7%) staff had one or more colony forming units of MRSA on their fingertips. (Most grades of staff had some positives although the majority of the positives were from staff working in two to three specific areas in the hospital). Following hand gel application, the above figure was reduced to 3/110 (2.7%).

This clearly illustrates the ‘in-use’ efficacy of this alcohol hand rub in reducing hand contamination with MRSA and we plan to repeat the exercise on a quarterly basis both as a method of surveillance and as a useful practical educational tool for staff.

Competing interests: None declared.

Arti Thakerar 4th Year Medical Student St Bartholomew’s & The Royal London Hospitals & School of Medicine arti_thakerar@doctorsworld.com

Collin Goodbourn Consultant Microbiologist Whipps Cross University Hospital NHS Trust, London E11 1NR

1 Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362-5. (17 August.)

Competing interests: None declared

Arti Thakerar, 4th Year Medical Student

Collin Goodbourn

St Bartholomew's & The Royal London Hospitals & School of Medicine

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23 August 2002

The authors say that they are not aware of a direct comparison of the glove juice technique and finger plating for assessing bacterial burden on hands.

I think the reference they need is:

Comparison of two methods for assessing the removal of total organisms and pathogens from the skin Ayliffe GAJ, Babb JR, Bridges K, Lilly HA, Lowbury EJL, Varney J & Wilkins MD (1975) Journal of Hygiene (Camb) 75 : 259

(not available on pubmed, which is presumably why they didn't find it).

From memory, this showed that both methods gave comparable results, but that the glove juice method was about twice as sensitive. I think this work helps to justify the authors' choice of method, which seems to me a sensible compromise.

Secondly, in the introduction the authors state that "recent studies have shown that this level of compliance will not reduce the risk of transmission of multiresistant bacteria in hospital", and refer to Austin DJ et al. Proc Natl Acad Sci U S A 1999; 96:6908-6913.

This is a misunderstanding of that paper's conclusion. In fact the paper merely argued that in that particular setting, based on the observed VRE prevalence, achievable levels of handwashing compliance were unlikely to be sufficient to reduce the basic reproduction number for VRE in the ward to below 1 (the basic reproduction measures the number of secondary cases caused by one primary case when the pathogen is first introduced to a ward. For there to be a substantial chain of transmission without reintroduction of the organism this number has to be greater than one). In fact, all increases in handwashing compliance should reduce transmission, and whether or not the basic reproduction number can be reduced below one depends on local conditions. In any case, even when the reproduction number is less than one considerable transmission can still occur if many patients import the pathogen to a ward, and any reduction in the reproduction number will reduce transmission and should be encouraged, whether or not a basic reproduction number of less than one can be attained.

The following reference might make some of these points clearer:

J Hosp Infect 1999 Oct;43(2):131-47 Preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects. Cooper BS, Medley GF, Scott GM.

Competing interests: None declared

Ben S Cooper, Research Fellow

Harvard School of Public Health, MA 02115

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During my several years in the medical microbiology laboratories, I have found alcohol rub to be quite safe and there has been no untoward reaction. I strongly recommend it as a safe and convenient way of reducing cross contamination.

Competing interests: None declared

Subramanyam R Vemulpad, Lecturer

Dept of Health & Chiropractic, Macquarie University, Sydney NSW 2109

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20 August 2002

The experience in this institution is that nurses who have had long term hand dermatitis from using the soaps, have experienced dramatic results after using alcohol degermers. Their hands have cleared up nicely, and have not had reoccurrence of dermatitis. The product we use has been so well accepted, that nurses have told me they no lionger need hand lotions. We have not had a single complaint regarding hand dermatitis. The only complaints have been regarding the smell, and fumes causing, "breathing problems". These have come from individuals with asthma, trachs, and other compromising lung conditions.

Competing interests: None declared

Deb R Paul-Cheadle, Infection Control, RN

100 Michigan, Grand Rapids Mich, 49503

Spectrum Health

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20 August 2002

We have read of a case where an alcohol based hand cleanser caught fire. Does anyone have any information on this case or on the incidence of fire with these products? We are making a decision on what product to use for a new dispensing system outside patient rooms. This is a very timely dialogue for us. Thanks for any answers! ck

Competing interests: None declared

Carol L. Kenyon, Cardiac Care Coordinator

Harlene Husted, RN, MSN, CIC, Infection Control

Delnor Hospital; Genva , IL 60134

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In Finland, we have used alcohol-based handrubs since 1980s and adopted handrubbing as a primary choice for hand hygiene in health care.

The HCW´s have accepted the method and we have had much less complaints of skin drying than during the use of other hand hygiene products (Ojajärvi & al, J Hyg 79: 107, 1977; Ojajärvi, J Hosp Inf 18, Suppl B: 35, 1991). The alcoholic preparations must of course contain skins emollients, such as 1 to 2 per cent glycerol to prevent drying of the skin.

Competing interests: None declared

Juhani Ojajarvi, senior medical officer

P.O. Box 55, 00301 Helsinki, Finland

National Agency fro Medicines, Medical Devices Centre

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