Effectiveness of Alcohol-based solutions for Hand Hygiene: A Systematic Review

Abstract

 

Hand hygiene is an important measure in reducing the transmission of nosocomial infections in hospitals, but adherence is poor among health care workers (HCWs).More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol.

Hand rubbing with alcohol-based products is commonly used in some countries instead of handwashing. This review evaluates the scientific and clinical evidence on the use of alcohol-based hand rubs in health care settings as a new option for hand hygiene.

Objectives 

To conduct a systematic review to determine the best available evidence related to effectiveness of alcohol-based solutions for hand hygiene. The specific review questions addressed were: the effectiveness in reducing microorganisms, compliance with hand hygiene, and the incidence of skin problems. Application time (consumption) addressed efficiency.

Criteria for considering studies in this review 

This review considered all studies that included alcohol-based solutions that related to the objectives of the review. Outcomes included measures for the reduction of organisms, compliance with hand hygiene, the types of skin problems, and application time. The review primarily considered any intra-individual trials (IITs), randomised controlled trials (RCTs) and controlled clinical trials (CCTs) relating to the effectiveness of alcohol-based solutions but also included quasi-experimental designs.

Search strategy for identification of studies 

The search sought to find published and unpublished studies. The databases searched included: Medline, CINAHL, ProQuest and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.

Assessment and data extraction 

All studies were checked for methodological quality by two reviewers and data were extracted using a tool.

Data analysis 

The study results were pooled in statistical meta-analysis using Review Manager software and summarized in narrative form where statistical pooling was not appropriate or possible.

Results 

This systematic review included thirty seven studies that supports the use of alcohol-based solutions for routine hand hygiene and surgical hand scrub. Alcohol-based hand rub removes microorganisms from hands of personnel more effectively, requires less time, and irritates hands less often than traditional handwashing with nonmedicated soap or other antiseptic agents and water. The combination of 61% ethanol and 1% chlorhexidine gluconate (CHG) is even more effective in producing residual antibacterial properties on the skin. Furthermore, the availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs.

Conclusion 

Rubbing hands with alcohol-based agents has been proved to be effective in the reduction of microorganisms from hands. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Addition of CHG to alcohol-based solution can produce residual antibacterial properties on the skin. The use of alcohol-based solutions containing emollients causes less skin irritation and dryness and requires less time than washing hands with soap or other disinfectants. The promotion of bedside, alcohol-based hand rubs contributes to the increase in compliance with hand hygiene by HCWs

Introduction

Health care workers can acquire pathogens from patients during their duty work and transmit them to susceptible patients. Microorganisms accumulate on HCWs' hands over time during patient care.¹ Therefore, hand hygiene is considered the most important measure for preventing nosocomial infections. Several guidelines and recommendations on hand hygiene have been published.^2–4 Recommended methods of hand hygiene include handwashing (washing hands with plain soap), hygienic handwash (washing hands with medicated soap), and hygienic hand-rub (use of antiseptic rubs). It is still unclear what kind of measure is the most effective. In 2002, a guideline for hand hygiene in health-care settings was published by a Hand Hygiene Task Force, comprising representatives from the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control (APIC), and the Infectious Diseases Society of America (IDSA).² This guideline included more detailed discussion of alcohol-based hand rubs and supported their use in clinical settings than had been recommended in earlier guidelines.

Studies have consistently shown that HCWs frequently do not wash their hands and compliance rarely exceeds 50%.^2,5 Several factors may contribute to this unsatisfactory rate including time limitations.⁶ Although conventional handwashing takes only about 10 seconds, the entire procedure of leaving the room, moving to the sink, adjusting the tap, drying the hands, and returning to the patient takes more than a minute.⁷ More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol.^2,4,8 Alcohol has been used as a skin antiseptic. Three alcohols are most appropriate for use on the skin: ethyl (ethanol), normal-propyl (n-propanol), and isopropyl. It was discovered that alcohols must be diluted with water for maximal antimicrobial activity and that preparations containing 60% to 90% alcohols are most effective.⁹

The selection of an appropriate antiseptic for hand hygiene should be based on the safety and efficacy in reducing microbial count. Rub-in hand disinfection with alcohol-based solutions was introduced into some hospitals for both hygienic and surgical hand disinfection many years ago. Presently, hand rubbing with alcohol-based products is commonly used in European countries instead of handwashing. It is shown that alcohols exert an excellent antimicrobial activity, which is more rapid than other disinfectants.¹⁰ They are also of low toxicity and irritate hands less often when made up with suitable emollient.¹ The use of Alcohol-based solutions has been shown to significantly improve compliance and have been associated with decreased infection rates.^5–6 The major disadvantage of alcohol for skin antisepsis is its drying effects. In addition, some people find the smell of alcoholic-based disinfectants unpleasant. Therefore, alcohol-based solutions have many advantages and only a few disadvantages compared to other hand disinfectants.

Although some hospitals still favor handwashing with soap or an antimicrobial detergent, recent studies have demonstrated that increased use of alcohol-based hand rubs can improve hand hygiene practices among HCWs.

This review evaluates the clinical evidence that investigates the use of alcohol-based hand rubs in hospitals as an alternative method for ensuring hand hygiene.

Objectives

The objective of this review was to determine the best available evidence related to the effectiveness and efficiency of alcohol-based solutions for hand hygiene.

The specific review questions addressed were:

• Are alcohol-based solutions effective in reducing the number of organisms on the hands of HCWs in hospitals and healthy volunteers?
• Does the introduction of alcohol-based solutions improve compliance with hand hygiene among HCWs?
• Is the use of alcohol-based solutions associated with skin disorder on hands?
• Is hand cleansing with alcohol-based solutions time effective compared to traditional methods for hand cleansing?

Criteria for considering studies in the review

Types of participants

This review considered all studies that included HCWs in hospitals and healthy volunteers.

Types of interventions

Interventions included:

• Contamination of hands of HCWs or healthy volunteers with microorganisms followed by a hygienic hand-rub using alcohol-based solutions
• Introduction of alcohol-based solutions in wards/units
• Application of alcohol-based solutions on hands or skin

Types of outcome measures

The outcomes of interest were the reduction of microorganisms (assessed using log reduction factor or other methods), compliance with hand hygiene, types and incidence of skin problems, and application time.

Types of studies

This review considered any prospective randomised clinical trials (RCTs), controlled clinical trial (CCTs), and intra-individual trials (IITs) that evaluated the effectiveness of alcohol-based solutions for hand hygiene. Quasi-experimental designs were also included with the results being incorporated in a narrative form.

Exclusion Criteria

This review excluded articles that were expert opinion, in vitro study, literature reviews, or included no detailed results of the study. A list of studies excluded and the reasons for their exclusion can be seen in Appendix 1.

Search Strategy

The search strategy was designed to identify both published and unpublished studies and comprised three stages:

• A limited search of Medline to identify relevant keywords contained in the title, abstract, and subject descriptors
• Terms identified in this way and the synonyms used by respective databases, used in an extensive search of the literature
• Reference lists and bibliographies of the articles collected from those identified in stage two above were also searched.

The initial search terms included alcohol, alcohol-based, handwashing, hand hygiene, and compliance.

The time period of the search covered articles published from January 1992 to April 2002 in English and Thai language covering a decade of research. It was considered that this time period was sufficient to identify all relevant research related to the use of alcohol based solutions for hand hygiene. The databases searched included: CINAHL, Medline and ProQuest. The search for unpublished studies included Dissertation Abstracts International.

All studies identified during the database search were assessed for relevance to the review based on the information provide in the title, abstract, and descriptor/MeSH terms, and full reports were retrieved for all studies that meet the inclusion criteria as assessed independently by two reviewers. Discrepancies in reviewer selections were resolved at a meeting between reviewers prior to selected articles being retrieved. Those studies meeting the inclusion criteria were submitted to critical appraisal.

Critical appraisal

Two reviewers independently critically appraised each study that met the inclusion criteria. Discrepancies in critical appraisal were resolved at a meeting between reviewers.

Methodological quality of RCTs / CCTs/ IITs was assessed using a checklist developed by the researcher based on the work of the Cochrane Collaboration and Centre for Reviews and Dissemination (Appendix 3). Methodological quality of quasi-experimental studies was assessed using a checklist developed by three researchers based on the related research methodology and piloted before use (Appendix 4). Those studies had to meet the criteria to be included in the review.

Data Extraction

Data that could be used as evidence were extracted, and the level of evidence was evaluated. Data were extracted from the included studies using a tool (Appendix 5) designed for this study and piloted by three researchers before use.

Data Analysis

Where possible study results were pooled in statistical meta-analysis using Review Manager software from the Cochrane Collaboration (Review Manager 4.1). Double data entry was undertaken to minimise risk of error. Weighted mean differences (WMD) or Peto odds ratio (Peto OR) and their 95% confidence intervals (CI) were calculated for each included study. Heterogeneity between combined studies was tested using a standard chi-square test.

Pooling of data from studies was initially based on comparable intervention and outcome measurement. Where possible, subgroup analysis was undertaken to determine the effectiveness of the introduction of alcohol-based solutions in improving compliance with hand hygiene among HCWs in different professional groups and types of units.

Where statistical pooling was not appropriate or possible, the findings were summarised in narrative form.

Definition

Log reduction factor (RF) measures how well a test solution decreases the amount of microorganisms on subjects' hands. It is calculated as RF = log ₁₀ (baseline bacterial count)- log₁₀(postwash bacterial count). A small value for RF means that there was only a small reduction in the number of bacteria on the hands after washing with the test formula. The FDA Tentative Final Monograph for Healthcare Antiseptic Drug Products (TEM) criteria for efficacy are as follows: a 2-log₁₀ reduction of the indicator organism on each hand within 5 minutes after the first use, and a 3-log ₁₀ reduction of the indicator organism on each hand within 5 minutes after the tenth use.²

The European norms 1500 (EN 1500) requirement means the standard by which the efficacy of products for hygienic hand disinfection such as hand rinses or gels are tested under practical conditions by comparison with the reference alcohol (n-propanol 60% volume per volume [v/v]) tested on E. coli K12 (NTCC 10538). The reduction factor of the test product should not be significantly less effective than the reference alcohol.²

Results

A total of 199 citations met the inclusion criteria and were retrieved. The review process outlined above resulted in a total of 37 articles that were considered as appropriate for inclusion as evidence. Fifty four percent (20/37) were RCTs/CCTs with nine IITs and eight quasi-experimental. The majority of the studies (23) related to effectiveness in reducing microorganisms, six to compliance with hand hygiene, 14 to skin problems, and three to application time.

Meta-analysis was conducted where studies of treatments and outcomes could be pooled. Some studies provided inadequate data for analysis and these studies are presented in narrative form as additions.

Effectiveness in reducing microorganisms

Twenty-three papers were included in the review of effectiveness of alcohol-based solution in reducing microorganisms For the purpose of analysis the range of interventions have been grouped according to type of alcohol-based disinfectant, product concentration, form of application modes, and type of microorganisms. Meta analysis was conducted where studies of treatments and outcomes could be pooled.

Various concentrations of alcohol-based disinfectant

1: Ethanol 62% compared with ethanol 70%

One CCT study¹²showed that in comparison to ethanol 62%, ethanol 70% was more effective in reducing bacteria on hands. (No information on significant)

2: Isopropanol 70%, 80%, and 90% compared to reference alcohol (N-propanol 60%)

Rotter et al¹³ found that the immediate effect of rubbing isopropanol 90% on to the hands for 3 minutes was as effective as reference alcohol (RF, 2.6 ± 1.1 vs 2.6 ± 1.0). But this effect was not statistically significant for the sustained effect (even 3 hours after disinfection and after gloves had been worn for this period) (RF, 1.4 ± 0.8 vs 1.6 ±0.9). At 80%, the immediate effect of this alcohol was slightly but not significantly smaller than the reference alcohol (RF,2.4 ± 0.8 vs 2.6 ± 1.0). At 70% the effect of isopropanol was significantly less than the reference alcohol both for immediate effect (RF, 2.1± 1.0 vs 2.6 ±1.0) and sustained effect (RF, 1.1 ±0.9 vs 1.6± 0.9).

3: Sterillium compared with reference alcohol

Pietch⁸ indicated that within 30 seconds after treatment with sterillium (45% w/w of propan-2-ol, 30% w/w of propan-1-ol, and 0.2% w/w of ethylhexadecyldimethyl ammonium ethylsulfate skin care ingredients, colour, and perfume), a mean RF of 4.26 ± 0.45 was found compared with the reference alcohol (4.10 ± 0.59). Therefore, sterillium passed the EN 1500 requirement within 30 seconds.

Hand rub compared with hand gel

Seven alcoholic gels were compared with the reference alcohol (2-propanol, 60%). The results showed that the mean reduction factors of alcoholic gels(RF = 2.13 - 4.07) was significantly lower than the reference alcohol (RF = 3.78 - 4.96) (p < 0.01). Therefore, none of the gels tested passed the EN 1500 requirements within 30 seconds.⁸

Kramer et al¹⁴compared ten alcohol-based hand gels with a content of up to 70% (v/v) and four alcohol-based hand rinses content of up to 75%(v/v) with the reference alcohol. However the mean microbial reduction factors of the reference alcohol varied from 3.70 to 5.07 and those of the gels from 2.13 to 4.09. The mean reduction factor of each gel was about 1 log-step lower than the reference alcohol (p<. 01). The mean reduction factor of the four hand rinses tested varied from 4.26 to 4.88 and did not differ significantly from that of the reference alcohol. Therefore, most alcohol-based hand rinses met the EN 1500 requirement within 30 seconds of application whereas the tested gel did not fulfil this criterion. As the study did not provide standard deviations the results could not be included in a meta graph.

Alcohol scrub compared with sponge and rubs

Hobson et al¹⁰ indicated that use of alcohol-based surgical scrub formulation (70% ethanol and surfactant, emollient, and preservative ingredients) without scrub brush produced results statistically similar to 3-minute applications with either brush or a sponge. The alcohol-based formulation passed the microbial reduction criteria required under the FDA's current Tentative Final Monograph for Healthcare Antiseptic Products criteria for surgical scrub in all 3-application modes tested.

Alcohol-based solution compared with nonmedicated soap

Four studies^15–18 demonstrated that rubbing hands with alcohol-based solution reduced the bacteria count from the hands significantly more efficiently than nonmedicated soap (p< 0.01). In addition, Dyer¹² found that 62% ethanol-based hand sanitizer formula had a degerming activity that was approximately 20% greater than the degerming activity of nonmedicated soap.

Alcohol-based solution compared with 4% chlorhexidine gluconate (CHG)

1: The immediate effect

Studies by Hobson et al and Pietschwere combinedin a meta analysis.

Figure 1: microbial reduction effect of alcohol-based solution and chlorhexidine gluconate

The meta-analysis that included two studies demonstrated that the microbial reduction effect of alcohol-based solution was significantly greater than that of 4% CHG immediately after application (WMD 1.10, 95% CI 1.01–1.19).^8,10

Kampf. et al¹⁹ found that sterillium rub was superior in comparison to Hibiclens

(chlorhexidine, 4%) regarding the bactericidal effect for the post contamination treatments of hands. Sterillium rub revealed a higher mean of log ₁₀ reduction at all times (e.g. 3.98 vs 2.21 after wash 1 or 3.60 vs 2.37 after wash 11).

2: The sustained effect

Larson et al²⁰ found that there was no significant difference in numbers of colony forming units (CFU) between participants in the 2% CHG and 61% ethanol with emollients groups at any time period (mid-day 1, week 2, and week 4). This result was consistent with Bryce, et al²¹ who reported that there was no statistically significant difference between the microbial counts following presurgical hand disinfectant with an alcohol-based product or 4% CHG/7.5% povidone iodine for cases less than 2 hours duration (0.21 vs 0.33). Comparison of longer surgical cases (cases of more than 3 hours duration) also showed no significant difference in microbial counts (+1.19 vs +0.69). However, Hobson et al¹⁰ demonstrated that alcohol-based surgical scrub (70% alcohol and surfactant, emollient and preservative ingredients) appeared to be capable of producing a statistically significant improvement for initial and persistent hand antisepsis characteristics. They found that there was a statistically significant improvement with using the alcohol based surgical scrub over the use of 4% CHG at all times on 5 days of application (p < 0.05). In contradiction, Mulberry et al²²found that the log reductions for 61% ethanol did not meet the TFM criteria for a surgical scrub product and proved to be less than that of the 4% CHG product at all times on days 1, 2, and 5.

The combination of alcohol and CHG or irgasan compared with CHG, ethanol, and soap

Two studies found that 1% CHG and 61% ethanol was more effective in reducing microbial counts post scrub than 4% CHG (p < 0.05).^22–23 Two studies found that the combination of CHG and alcohol significantly reduced bacteria compared to 61% ethanol (P < 0.01)²²and 70% ethanol (p< 0.001)²⁴. The study by Sae Ung et al²⁵ showed that the reduction of bacteria on HCWs' hands was 30% - 50% when washed with soap and over 90% when rubbed with a solution of 0.5% CHG and 70% ethanol. The greatest reduction of bacterial counts persisted in the rubbing groups at 5 and 10 minutes.²⁵ Trakulsomboon et al found that Desmanol (the combination of chlorehexidine dihydrochloride plus propanol) and Virulex (Irgasan 0.5% DP300, in alcohol) proved similarly efficacious.²⁶ Percentage of bacterial reduction of 99.9% was demonstrated in all except one (97.7%) of the 30 subjects for both reagents. (Table 1)

Table 1: Studies comparing the relative efficacy of the combination of alcohol and CHG or irgasan versus CHG or alcohol or soap in reducing counts of viable bacteria on hands

Alcohol-based solution compared with povidone iodine

Hobson et al demonstrated the alcohol-based preparation significantly reduced bacterial count compared with 7.5% povidone iodine (p<.05).¹⁰

Alcohol-based solution compared with benzalkonium chloride (0.13% v/v)

Dyer et al¹² found that benzalkonium chloride (SAB) and 62–70% ethanol were equally effective in reducing microorganisms after a single application (RF, 2.8 ±0.2). After repeated use, the ethanol did not meet FDA standards, although the SAB did. However the study by Moadab et al²⁷ showed that the antimicrobial activity of alcohol-based hand gel (Purell) was significantly less effective than benzalkonium chloride (0.13% v/v) (HandClens) (p<. 001).

Alcohol-based solutions against multiple drug resistant microorganisms

1: Alcohol-based solution compared with nonmedicated soap to reduce Methicillin Resistance Staphylococcus Aureus (MRSA)

Two studies showed that the alcohol-based solution was more effective than nonmedicated soap for reducing MRSA. Guihermetti et al²⁸ found that the 70% ethyl alcohol was more effective than non medicated soap for reducing MRSA (RF, 3.27 and 1.77, respectively)

(p< 0.05).In a similar study, Huang et al²⁹ compared 80% ethyl alcohol with liquid soap.²⁷The removal rate (the percentage of bacteria removed from the MRSA-contaminated fingertrips) was noted to be more for ethyl alcohol (99.1% vs 96.1%).

2: Alcohol-based solution compared with 4% CHG against MRSA

The results of two studies shows that the alcohol-based disinfectant was significantly more effective than 4% CHG in reducing MRSA. Guihermetti et al²⁸found that 70% ethyl alcohol had significantly higher removal rates than 4% CHG (RF, 3.27 and 1.37, respectively)

(p< 0.05). In addition, Huang et al²⁹ compared 80% ethyl alcohol with 4% CHG and removing rate was noted to be more for ethyl alcohol (99.1% vs 97.2%).

3: Alcohol-based solution compared with povidone iodine against MRSA

The study by Guihermetti et al²⁸showed that a 10% povidone iodine detergent containing 1% iodine (PVP-1) had higher removal than 70% ethyl alcohol (RF, 4.39 vs 3.27). But Huang et al²⁹ reported that the removing rates for 7.5% PVP-1 and 80% ethyl alcohol were not significantly different (99.2% ±0.4% vs 99.1% ± 0.8%).

Alcohol-based solution against viruses

Sattar et al³⁰ found that alcohol-based hand gel reduced virus infectivity including adenoviruses, rhinoviruses and rotaviruses by 3 to > 4 log₁₀ when compared to a reduction of £ 1 log₁₀ for the hard water (water with a standard hardness of 200 ppm as calcium carbonate) rinse. In addition, Bellamy et al³¹found that alcohols and alcohol based product produced the greatest log reduction (2.85 to 3.93). All other treatments, including soap, detergent formulations, and water alone were generally inferior to alcohols. Log reductions of between 0.46 and 2.13 were obtained for these treatments.

The interactions of hand care products on the microbicidal efficacy of different alcohol hand-rubs

Heeg³² conducted two trials to investigate the impact of hand care products on the microbicidal efficacy of alcohol hand-rubs. The results indicated that the mean RF for three hand-rubs varied between 4.03 and 4.22 compared with 3.76 and 4.43 for six possible combinations of hand-rubs and hand gel products applied immediately prior to disinfection. Differences between reduction factors achieved with hand-rubs alone and in combination with hand care were not significantly different.

Compliance with hand hygiene

The evidence that introduction of hand-rubbing with an alcohol-based solutions in intensive care units and others areas improve compliance with hand hygiene among HCWs is strengthened by this review of studies.

Figure 2: compliance with hand hygiene by health-care workers with and without the introduction of hand-rubbing with an alcohol-based solutions

Six studies reported that compliance significantly improved from 23.4%-62.2% to 48.4%-66.5%.^6,33–38 Most of these studies involved the promotion of alcohol-based products together with an educational program and other interventions such as performance feedback and poster campaign. However, all these studies indicated that compliance improved mainly as a result of the increased use of alcohol-based hand rub solution. The combined result significantly favoured the introduction of alcohol-based solution (Peto OR 1.96, 95%CI 1.56–2.46).

Four studies indicated that nurses were more compliant than physicians and other HCWs in regards to hand hygiene.^6,33–34,38 Furthermore, it was found in the study by Pittet et al³⁴ that average compliance differed between hospital locations and compliance improved significantly during the period of introducing alcohol-based antiseptic in medical, surgical, and intensive care wards (all p<0.001).Changes in compliance were not statistically significant in gynaecological/obstetrics (p=0.17) and paediatric wards (p=0.12).

Skin problems

In comparing the effect of alcohol-based solution to soap or other antiseptic solutions in relation to skin problems, various skin assessment were used including dryness and irritation. Several studies^{6,8,20–23,39–40,42,44} used either subjective or objective assessment methods and some studies^{10,41,43–44} used both methods to evaluate skin irritation and dryness arising from the use of alcohol-based solution for hand hygiene. The findings were summarised in narrative form because the studies used a variety of interventions and outcome measurements. Among the 14 studies designed to test the effect of alcohol-based solution on skin condition, five tested before and after^6,10,39–41, one compared alcohol-based solution and soap,⁴² and eight compared alcohol-based solution and chlorehexidine.^{8,20–24,43,45} Results in relation to each of these are presented below.

1: Before and after use of alcohol-based solution

Four studies found no significant increase in skin problems due to the use of alcohol-based solution.^10,39–41 Most of the skin irritation problems could be controlled with more frequent skin care. In addition, one study indicated that after using an alcohol-based hand rubs, there was a significant decrease in dryness of hands (p = 0.002).⁶

2: Alcohol-based solution compared to soap

Boyce et al⁴² found that skin irritation and dryness increased significantly when nurses washed their hands with an unmedicated soap product rather than disinfecting their hands with an alcohol-based gel.

3: Alcohol-based solution compared to CHG

Eight studies reported comparing the effects of alcohol-based solution and CHG on skin condition. Six of them found that alcohol-based solutions were less damaging to the skin than CHG,^{8,20,22–24,43}and the other two found no difference.^21,45

Time consumption for alcohol hand disinfectionand compliance

There were three studies that reported application time in using alcohol-based solutions. The study by Voss and Widmer⁷ in 1997 indicated that it took intensive care unit nurses approximately 60 seconds for handwashing whereas use of an alcohol-based antiseptic available at each patient's bed required only 15 seconds. In addition, given 100% compliance, handwashing with water and soap would consume 16 hours of nursing time (17% of the total work force) per day shift, whereas bedside hand disinfection with an alcoholic rub would require only 3 hours (< 3% of the work force, p=. 01). Similar results were obtained in two studies by Larson et al. The first indicated a 41% decrease in application time when using alcohol-based solution compared with CHG (p=. 0001).²⁰ The second study found that a significantly reduced length of time was required for a waterless hand rinse product containing alcohol-based solution than for the traditional surgical hand scrub (CHG)(2 minutes vs 6 minutes).²³

Conclusion

This systematic review highlighted a considerable amount of evidence to support the use of alcohol-based hand rubs for routine hand hygiene. The majority of studies of alcohol-based solutions have evaluated individual alcohols in varying concentrations. Other studies have focused on combinations of two alcohols or alcohol solutions containing limited amounts of CHG, N-duopopenide or triclosan. Numerous studies have demonstrated that alcohol-based hand- rubs remove microorganisms including bacteria, viruses, and multiple drug resistant microorganisms from hands of personnel more effectively than washing hands with nonmedicated soap or other antiseptics. Isopropanol 90% is as effective as n-propanol 60% in antimicrobial activity and ethanol- based formulation should contain at least 70% ethanol (v/v). Most alcohol-based hand rinses meet the EN requirement within 30 seconds. Although two studies indicated that antimicrobial efficacy of alcohol-based hand gels did not pass the EN 1500 within 30 seconds whereas the rinses did. However, two studies showed that 60%-70% ethanol hand gel gave the best reduction of virus titre compared to hand water rinse/soap/4% CHG. Alcohols are effective for preoperative cleansing of hands of surgical personnel. Brushless application of the alcohol-based surgical scrub formulation for a duration of 3 minutes yielded satisfactory results for use as an effective surgical hand scrub. The combination of alcohol and CHG was even more effective in reducing counts of microorganisms and produced residual antibacterial properties on the skin.

Data from several studies consistently demonstrated that alcohol-based formulations for hand disinfectants are less irritating on skin than washing hands with soap and water or any antiseptic detergents. Frequent use of alcohol can dry the skin, but the addition of suitable emollients to alcohol hand rinses greatly reduces this problem. One study showed that the efficacy of alcohol-based hand rubs does not impair in respect to hand disinfection when they are used in combination with selected, comparable hand care products.

The acceptability of alcohol hand rubs among HCWs is greater than that of frequent handwashing. Several studies showed that increasingly accessible alcohol-based, waterless hand antiseptic increased compliance with hand hygiene among HCWs. Nurses complied with hand hygiene more than physicians and others. In addition, compliance improved significantly the ICU during the period of introduction of alcohol-based solutions than other units.

Handrubs with alcohol required less time than handwashing with soap or disinfectants in clinical conditions. The shorter time required for use of the alcohol hand rub might explain the enhanced compliance with hand hygiene among HCWs.

Summary of findings

The findings of this systematic review are summarised as follows. Findings are categorized using NHMRC levels of evidence (Appendix 7).

1. Rubbing hands with alcohol-based agents has been proved to be more effective in the reduction of microorganisms including bacteria and virus from hands than washing hands with soaps or other antiseptic agents and water. (Level I)
2. The application of the alcohol-based hand rinse reduces bacterial counts on the hands more than the gel tested. (Level II)
3. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Addition of CHG to alcohol-based solution can produce residual antibacterial properties on the skin. (Level II)
4. The use of alcohol-based solutions containing emollients causes less skin irritation and dryness and requires less time than washing hands with soap or other disinfectants. (Level II)
5. The promotion of bedside, alcohol-based hand rubs contributes to the increase in compliance with hand hygiene by health care workers. (Level III.I)

Recommendations

• Alcohol-based hand rubs should be used for routine hand hygiene in preference to hand washing with soaps or other antiseptic agents and water.
• Further research should be conducted to examine:
• the association between use of alcohol-based solutions for hand hygiene of health care workers and reduction in nosocomial infection rates among patients.
• the effect of bedside, alcohol-based hand rubs on long term compliance with hand hygiene by health care workers.