Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Efficacy of hand rubs with a low alcohol concentration listed as effective by a national hospital hygiene society in Europe

Background

Some national hospital hygiene societies in Europe such as the French society for hospital hygiene (SFHH) have positive lists of disinfectants. Few hand disinfectants with a rather low concentration of ethanol are listed by one society as effective for hygienic hand disinfection with 3 mL in 30 s including a virucidal activity in 30 s or 60 s, but published data allow having doubts. We have therefore evaluated the efficacy of three commonly used hand disinfectants according to EN 1500 and EN 14476.

Methods

Products 1 (Aniosgel 85 NPC) and 2 (Aniosrub 85 NPC) were based on 70% ethanol, product 3 (ClinoGel derma+) on 60% ethanol and 15% isopropanol (all w/w). They were tested in 3 laboratories according to EN 1500. Three mL were applied for 30 s and compared to the reference treatment of 2 × 3 mL applications of isopropanol 60% (v/v), on hands artificially contaminated with Escherichia coli. Each laboratory used a cross-over design against the reference alcohol with 15 or 20 volunteers. The virucidal activity of the products was evaluated (EN 14476) in one laboratory against adenovirus and poliovirus in different concentrations (80%, 90%, 97%), with different organic loads (none; clean conditions; phosphate-buffered saline) for up to 3 min.

Results

Product 1 revealed a mean log₁₀-reduction of 3.87 ± 0.79 (laboratory 1) and 4.38 ± 0.87 (laboratory 2) which was significantly lower compared to the reference procedure (4.62 ± 0.89 and 5.00 ± 0.87). In laboratory 3 product 1 was inferior to the reference disinfection (4.06 ± 0.86 versus 4.99 ± 0.90). Product 2 revealed similar results. Product 3 fulfilled the requirements in one laboratory but failed in the two other. None of the three products was able to reduce viral infectivity of both adenovirus and poliovirus by 4 log₁₀ steps in 3 min according to EN 14476.

Conclusions

Efficacy data mentioned in a positive list published by a society for hospital hygiene should still be regarded with caution if they quite obviously contradict published data on the same or similar products.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure.

OBJECTIVES

To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond twelve months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.

AUTHORS' CONCLUSIONS

The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.

Role of hand hygiene in healthcare-associated infection prevention

Healthcare workers' hands are the most common vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the healthcare environment. Hand hygiene is the leading measure for preventing the spread of antimicrobial resistance and reducing healthcare-associated infections (HCAIs), but healthcare worker compliance with optimal practices remains low in most settings. This paper reviews factors influencing hand hygiene compliance, the impact of hand hygiene promotion on healthcare-associated pathogen cross-transmission and infection rates, and challenging issues related to the universal adoption of alcohol-based hand rub as a critical system change for successful promotion. Available evidence highlights the fact that multimodal intervention strategies lead to improved hand hygiene and a reduction in HCAI. However, further research is needed to evaluate the relative efficacy of each strategy component and to identify the most successful interventions, particularly in settings with limited resources. The main objective of the First Global Patient Safety Challenge, launched by the World Health Organization (WHO), is to achieve an improvement in hand hygiene practices worldwide with the ultimate goal of promoting a strong patient safety culture. We also report considerations and solutions resulting from the implementation of the multimodal strategy proposed in the WHO Guidelines on Hand Hygiene in Health Care.