Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection

With the new Centers for Disease Control and Prevention (CDC) guideline on hand hygiene, hospitals often introduce alcohol-based hand rubs for hand disinfection. Healthcare workers, however, may reject the new products because of skin irritation or other skin-related problems, which they experience after years of handwashing. In order to facilitate a successful introduction and continued use of alcohol-based hand rubs in hospitals, we have reviewed and summarized the major studies on the topic. Occupational hand dermatitis may occur in up to 30% of healthcare workers. It is mainly described as an irritant contact dermatitis caused by detergents. The diagnosis is usually clinical. Allergic reactions are very rare. After using an alcohol-based hand rub for the first time, healthcare workers may have a burning skin sensation that can be explained by pre-irritated skin. In this case the skin barrier has usually been impaired by frequent handwashing or occlusive gloves. This may result in a vicious circle whereby the healthcare worker increases the frequency of handwashing and reduces the frequency of hand disinfection. Prevention of irritant contact dermatitis is possible by selection of a low-irritating hand rub, which contains emollients, the correct use of the hand rub and a clear guideline when to disinfect and wash hands in the clinical setting. Common mistakes in the use of alcohol-based hand rubs are application to pre-irritated skin and washing hands before hand disinfection, which is, in general, not necessary, or after hand disinfection, which results in washing off the emollients. Clear preparation and guidance of healthcare workers before the introduction of alcohol-based hand rubs can help to enhance compliance in hand hygiene. The switch from handwash to alcohol-based hand rub will improve healthcare workers skin if mistakes are avoided and hand rinses are used correctly.     

Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs

Tests were performed under working practice conditions to measure the tolerance and acceptability of commercially available hand rubs with proven efficacy. The products were compared with those in current use at the Hospices Civils de Lyon for surgical hand disinfection (Sterillium) and hygienic hand disinfection (Purell) to obtain information for public sector purchases. The 12 test products were Alcogel H, Assanis Pro, Clinogel, Dermalcool, Manugel Plus, Manugel Plus NPC, Manurub Liquid, Manurub Gel, Purell 85, Spitacid, Spitagel and Sterillium Gel. They were tested from mid-November to mid-April over four periods of three weeks, separated by two-week intervals during which the customary product was re-introduced. Participation of hospital wards and theatres was voluntary. Skin dryness and irritation were scored before and after each test period. Acceptability and ease of use were assessed by means of a questionnaire. Among the eight surgical hand rubs, only Manurub Liquid, Manurub Gel and Manugel Plus NPC did not cause significantly more dryness and irritation than Sterillium. For the 10 hygienic hand rubs, differences were noted depending upon the test period. Overall, Assanis Pro, Clinogel, Purell 85 and Sterillium Gel did not cause significantly more dryness and irritation than Purell. However, over the (colder) first three test periods, Assanis Pro and Sterillium Gel caused more irritation and Purell 85 caused more dryness than Purell. Responses to the questionnaires on acceptability indicated that users preferred their customary hand rubs (Sterillium and Purell). As these field tests involving many participants did not identify any superior products, previous purchase orders were renewed.     

Efficacy of alcohol-based gels compared with simple hand wash and hygienic hand disinfection

A recent research letter on the limited efficacy of alcohol-based hand gels has alerted the global infection control community and raised the question of the true significance of data obtained according to EN 1500. It has been described that a 1 min simple hand wash reduces artificial contamination of hands by a log(10) reduction factor of 2.8 and a 1 min reference hand disinfection with 2-propanol (60%, v/v) by a factor of 4.6 steps. The EN 1500 gel data show that the 30 s efficacy of most gels is closer to a simple hand wash than to the reference hand disinfection. The 30 s efficacy of most alcohol-based liquid products and one gel, however, is almost identical to the reference hand disinfection. In many European countries alcohol-based liquid products have been established as a standard practice in hygienic hand disinfection for decades. Replacement of these products with most available gels would be a step backward in terms of efficacy and has still to be seen critically from the efficacy point of view.     

Clinical double-blind trial on the dermal tolerance and user acceptability of six alcohol-based hand disinfectants for hygienic hand disinfection

Six commercially available alcohol-based hand rubs [AHD 2000, Desderman, Mucasept A, Manorapid (Poly-Alkohol, Spitacid, and Sterillium] were investigated in a clinical double-blind trial involving 10 participants who had no previous experience of using hand rubs (Group 1), and seven who had substantial professional experience of using hand rubs (Group 2; virology laboratory staff). Group 1 was studied for one week with 20 applications on day 1 and then five applications per day for six days. Transepidermal water loss, dermal water content and superficial sebum content of the skin were measured before and after the seven-day application of the products, as well as user acceptability (self-assessment of smell, speed of drying, emolliant effect, skin dryness). Group 2 used each preparation twice for two weeks in a random sequence, and carried out self assessment at the end of each fortnight. Transepidermal water loss (mean baseline: 18.7 g/m(2)h), dermal water content (mean baseline dorsum: 75.6) and superficial sebum content (mean baseline dorsum: 4.8 microg/cm(2)) did not change significantly. In both groups assessments of the smell and the speed of drying did not reveal any significant differences between the six products. Sterillium had the best emollient effect of all products (P<0.05; Wilcoxon test and Mann-Whitney-U test) and was significantly better than Desderman, AHD 2000, and Mucasept A, causing less skin dryness after seven days use in Group 1 (P<0.05; Mann-Whitney-U test). Manorapid caused significantly less dryness than Spitacid, AHD 2000, and Mucasept A in Group 2 after the first use, but no significant difference was observed after the second use. Thus alcohol-based hand rubs that contain emolliants, irrespective of the type of alcohol (n-propanol, iso-propanol or ethanol), are well tolerated and do not dry out or irritate the skin. Personal assessments showed significant differences for the emolliant effect and the extent of dryness. Both factors are very important, as user acceptability has an impact on compliance. Sterillium is the only hand disinfectant containing mecetronium etilsulphate which has been shown to have an emolliant effect. Future research should focus on user acceptability in order to improve compliance.     

Efficacy of 2 alcohol-based gels and 1 alcohol-based rinse for surgical hand disinfection.

We assessed the efficacy of 2 alcohol-based gels and 1 alcohol-based rinse for surgical hand disinfection, using European standard EN 12791. Volunteers performed surgical hand disinfection with a reference product and each of the 3 study products, with 1-week intervals between disinfection episodes. The immediate and sustained antimicrobial activities of each study product were not significantly less than those of the reference product. The study products passed the efficacy requirements of the EN 12791 standard, and they are considered suitable for surgical hand disinfection.     

Comparison of the antibacterial efficacy and acceptability of an alcohol-based hand rinse with two alcohol-based hand gels during routine patient care

The aims of this study were to compare the antibacterial efficacy of handrubbing with an alcoholic rinse (AHRR) and two different alcoholic gels (AHRG) in reducing hand contamination under practical use conditions. We wanted to assess the acceptability of the three products and to determine the effect of each product on overall hand hygiene compliance. A prospective alternating time-series clinical trial was performed in a medical intensive care unit. The study was divided into three six-week periods (P1, P2, P3). Handrubbing was achieved with Sterillium rinse (AHRR) during P1, sterillium gel(AHRG-1) during P2 and Manugel Plus (AHRG-2) during P3. Pre- and post-rubbing hand contaminations were assessed immediately after a direct contact with a patient, using the glove juice technique. Health care workers (HCWs) evaluated the acceptability of the products through a self-administered anonymous questionnaire. Compliance of HCWs with hand hygiene was assessed during the three periods. We studied 242 handrubbing opportunities. The mean reduction factor (expressed as the Log(10) CFU/mL) of the AHRR, AHRG-1 and AHRG-2 were 1.28+/-0.95, 1.29+/-0.84 and 0.51+/-0.73, respectively (p<0.001). Assessment of the three products by HCWs indicated that AHRR and AHRG-1 were significantly better accepted than AHRG-2. The overall compliance of HCWs to hand hygiene was better when gel was available. Under practical use conditions, AHRG-1 and AHRR were more effective than AHRG-2, although all were claimed to pass the European standard EN1500. In vivo trials are essential to compare the antimicrobial efficacy of products for handrubbing.     

Determination of antiseptic efficacy of rubs on the forearm and consequences for surgical hand disinfection

Few standardised data are available on mortality rates in patients with Clostridium difficile infection (CDI). The literature often reports 'attributable' mortality or cannot be universally applied. We aimed to investigate the pattern and trends in all-cause mortality in a large unselected cohort of patients affected by CDI. This was done by means of a retrospective cohort study between 2002 and 2008 of all patients with positive stool toxin tests indicating CDI in one National Health Service (NHS) Trust, comprising three general hospitals and seven community hospitals. Vital status of the patients was determined from two sources. In total, 2571 patients with a first episode of CDI were identified (1638 females; median age 82.1 years). Cumulative mortality at 7 days, 14 days, 30 days and 1 year was 13.4%, 20.8%, 32.5% and 58.7%, respectively. There was no significant difference in mortality between sex, year of diagnosis or hospital site. Mortality at 30 days increased incrementally from 3.4% in those aged <40 years to 41% in those >90 years. Mortality rates were significantly higher than reported by previous studies but were remarkably consistent over the time period and between different hospitals within the Trust. Prognosis falls with increasing age, and the age of this cohort may explain the high 30-day absolute mortality. CDI infection is associated with high early mortality. To reduce mortality, new interventions need to be introduced soon after diagnosis. There is a need for standardised outcome data for CDI.     

两种消毒方法对X射线防护服消毒效果的比较

目的比较使用伽玛医用消毒湿巾与75%乙醇对X射线防护服表面消毒的效果,为选择合理的消毒方法提供依据。方法选取X射线防护服62件,其中手术室30件,导管室32件。随机分为试验组和对照组,每组各31件。试验组采用伽玛医用消毒湿巾、对照组采用75%乙醇对X射线防护服表面进行擦拭消毒,比较两者的消毒效果、消毒待干时间及使用成本。结果试验组与对照组细菌菌落数均值在消毒前分别为2.38 CFU/cm2及2.36 CFU/cm2,合格率分别为80.64%和83.87%。两组消毒后细菌培养均未检出细菌。试验组X射线防护服消毒平均待干时间为（352.35±9.93）s,低于对照组的（676.13±10.62）s,差异有统计学意义（t=123.98,P＜0.01）。试验组消毒X射线防护服每次的成本比对照组节省29.60%。结论使用75%乙醇与伽玛医用消毒湿巾对X射线防护服消毒效果均可靠,与75%乙醇相比,伽玛医用消毒湿巾对X射线防护服无腐蚀、消毒待干时间短、节省使用成本。     

Lack of association between the increased incidence of Clostridium difficile-associated disease and the increasing use of alcohol-based hand rubs.

OBJECTIVE: To determine whether there is an association between the increasing use of alcohol-based hand rubs (ABHRs) and the increased incidence of Clostridium difficile-associated disease (CDAD). SETTING: A 500-bed university-affiliated community teaching hospital. METHODS: Use of ABHRs during the period 2000-2003 was expressed as the number of liters of ABHR used per 1000 patient-days. The proportion of hand hygiene episodes performed by using an ABHR was determined by periodic observational surveys. CDAD was defined as a physician-ordered stool assay positive for C. difficile toxin A or A/B. The incidence of CDAD was expressed as the number of unique patients who had 1 or more positive CDAD test results per 1,000 patient-days. RESULTS: During 2000-2003, the use of ABHR increased 10-fold, from 3 to greater than 30 L/1,000 patient-days (P<.001). The proportion of hand hygiene episodes performed using an ABHR increased from 10% to 85% (P<.001). The incidence of CDAD in 2000, 2001, 2002, and 2003 was 1.74, 2.33, 1.14, and 1.18 cases/1,000 patient-days, respectively. CONCLUSION: Despite a significant and progressive increase in the use of ABHRs in our facility during a 3-year period, there was no evidence that the incidence of CDAD increased. These findings suggest that factors other than the increased use of ABHRs are responsible for the increasing incidence of CDAD noted since 2000 in other facilities.     

两种清洗消毒方法对消化内镜清洗消毒效果的比较

目的比较使用全自动清洗消毒机和传统手工清洗消毒方法对消化内镜清洗消毒效果的影响。方法收集某院消化内镜中心的109条消化内镜,根据编号分为试验组和对照组,试验组采用全自动清洗消毒机进行清洗消毒,对照组采用传统手工清洗消毒方法,对两组内镜不同部位进行采样。采用目测法结合ATP生物荧光检测法检测内镜的清洗质量,采用倾注培养法检测内镜的染菌量。比较两组内镜的清洗、消毒合格率。结果试验组共55条内镜,对照组共54条内镜。试验组内镜清洗总合格率为94.55%,对照组内镜清洗总合格率为83.33%,两组比较差异无统计学意义(P0.05)。其中试验组内镜阀门的清洗合格率高于对照组(96.36%vs85.19%),差异有统计学意义(P0.05),而内镜表面、内镜管腔清洗合格率比较,差异均无统计学意义(均P0.05)。试验组内镜消毒总合格率为96.36%,对照组内镜消毒总合格率为85.19%,两组比较差异有统计学意义(P0.05)。试验组内镜管腔消毒合格率高于对照组(96.36%vs 85.19%),差异有统计学意义(P0.05),而两组内镜表面、阀门两个部位的消毒合格率比较,差异均无统计学意义(均P0.05)。结论全自动清洗消毒机对于消化内镜的清洗消毒效果要优于传统的手工清洗消毒。如采用传统的手工清洗消毒内镜,则需要严格执行软式内镜的清洗消毒规范,最大限度地降低内镜诊治发生交叉感染的风险。     

Comparison of qualitative and quantitative fit-testing results for three commonly used respirators in the healthcare sector

N95 filtering facepiece respirators are used by healthcare workers when there is a risk of exposure to airborne hazards during aerosol-generating procedures. Respirator fit-testing is required prior to use to ensure that the selected respirator provides an adequate face seal. Two common fit-test methods can be employed: qualitative fit-test (QLFT) or quantitative fit-test (QNFT). Respiratory protection standards deem both fit-tests to be acceptable. However, previous studies have indicated that fit-test results may differ between QLFT and QNFT and that the outcomes may also be influenced by the type of respirator model. The aim of this study was to determine if there is a difference in fit-test outcomes with our suite of respirators, 3M - 1860S, 1860, AND 1870, and whether the model impacts the fit-test results.

Subjects were recruited from residential care facilities. Each participant was assigned a respirator and underwent sequential QLFT and QNFT fit-tests and the results (either pass or fail) were recorded. To ascertain the degree of agreement between the two fit-tests, a Kappa (Κ) statistic was conducted as per the American National Standards Institute (ANSI) respiratory protection standard. The pass-fail rates were stratified by respirator model and a Kappa statistic was calculated for each to determine effect of model on fit-test outcomes.

We had 619 participants and the aggregate Κ statistic for all respirators was 0.63 which is below the suggested ANSI threshold of 0.70. There was no statistically significant difference in results when stratified by respirator model.

QNFT and QLFT produced different fit-test outcomes for the three respirator models examined. The disagreement in outcomes between the two fit-test methods with our suite of N95 filtering facepiece respirators was approximately 12%. Our findings may benefit other healthcare organizations that use these three respirators.     

Application of the hygienic hand-disinfection test to the gloved hand

The Austrian Standard Hygienic Hand-Disinfection Test was adapted for comparing the effect of washing artificially contaminated hands (using Escherichia coli) with contaminated gloved hands, using liquid soap and rinsing with water. Tests showed that a single soap wash completely removed all the bacteria from the glove, and was more than 1000 times more effective on the glove than on the hand.     

两种手卫生依从率调查方法的比较

目的评价科室兼职感染控制人员（兼职人员）进行手卫生依从性目标性监测的可靠性。方法2014年12月某院医院感染管理科专职人员（专职人员）及兼职人员均采取隐蔽性观察方法进行手卫生依从率调查,前者在上午临床查房、治疗及护理操作高峰时段观察,后者在日常工作中进行观察,比较两种方法调查的数据。结果专职人员调查的医务人员手卫生依从率为36.67%（110/300）,低于兼职人员调查的61.90%（533/861）;不同科室、不同手卫生时刻,专职人员调查的手卫生依从率均低于兼职人员调查的数据（均P＜0.01）。专职人员与兼职人员的调查结果均显示,血液透析室、重症监护室病房（ICU）的手卫生依从率较高;清洁/无菌操作前、血液/体液暴露后、接触患者后手卫生依从率较高。 结论兼职人员调查的手卫生依从率偏高,但不同时刻手卫生依从率的高低与专职人员调查一致,有一定的可取之处。     

应用全面质量管理提高医务人员卫生手消毒依从性

目的探讨如何有效提高临床医务人员的卫生手消毒依从性。方法应用全面质量管理（TQM）理论和方法（以2008年6月调查资料为基线信息,2009-2010年为干预措施实施、巩固阶段,2010年进行汇总）,针对造成医务人员卫生手消毒依从性差的主要原因采取一系列措施,通过循环改进,逐步提高医务人员卫生手消毒的依从率。结果2008年6月-2010年6月共进行专项调查3次,通过多项干预措施,医务人员卫生手消毒的依从率逐年上升,从最初2008年的35.23%(315/894)上升至2010年的53.11%(563/1 060),两者比较,差异有高度显著性（χ2＝62.65,P＜0.01）。结论应用TQM法能有效提高临床医务人员卫生手消毒的依从性。     

Intra-laboratory reproducibility of the hand hygiene reference procedures of EN 1499 (hygienic handwash) and EN 1500 (hygienic hand disinfection)

The bactericidal efficacy of hand antiseptic products is determined in Europe using two norms--EN1499 (hygienic handwash), and EN 1500 (hygienic hand disinfection) based on reducing the counts of bacteria on artificially contaminated hands. Each requires 12-15 data sets per test and comparison with a reference procedure. Recent research using EN 1500 suggested that most alcohol-based hand gels are significantly less effective than the reference alcohol (2-propanol 60%), whereas liquid alcohol-based rubs are not. However concerns about the accuracy and reproducibility of the norm reference procedures have been raised. We therefore analysed 23 experiments carried out using EN 1500 representing 342 hand disinfection procedures, and 12 experiments using EN 1499 representing 178 handwashes, all performed in the same laboratory for reproducibility of the reference procedures. The reference alcohol gave a mean log(10) reduction factor (RF) of 4.64 +/- 0.93; only one data set gave a significantly higher result (5.14, P = 0.034), and one significantly lower (4.05; P = 0.034). Analysis of all 23 means revealed no significant difference (P = 0.188; ANOVA model). The reference soap gave a mean reduction of 2.82 +/- 0.49. Two data sets were significantly higher than this (3.35,P < 0.001; 3.12, P < 0.001) and two significantly lower (2.55, P = 0.031; 2.47,P = 0.004). Analysis of all the means did reveal a significant difference (P < 0.001, ANOVA model), which is probably explained by the smaller standard deviations of these results. Pre-values (bacteria recovered from fingers before a reference procedure) correlated significantly with RFs for both hand disinfection (correlation coefficient: 0.291;P = 0.01) and handwash (correlation coefficient: 0.372, P = 0.01). Overall both procedures gave accurate and reproducible results.     

二种血清淀粉酶测定方法的比较

急性胰腺炎是胰酶在胰腺内被激活后引起胰腺组织自身消化的化学性炎症。临床以急性上腹痛、恶心、呕吐、发热、血与尿淀粉酶增高为特点。血清淀粉酶在起病后6～12h开始增高,48h开始下降,持续3～5d。淀粉酶分子量约50000,可通过肾小球滤出。尿淀粉酶于起病后12～24h开始增高,持续1～2周。血清淀粉酶（删S）测定是急性胰腺炎诊断的最常用指标。     

Efficacy of three ethanol-based hand rubs against feline calicivirus, a surrogate virus for norovirus

We investigated the efficacy of three ethanol-based hand rubs (Sterillium Virugard, 95% ethanol; Sterillium Rub, 80% ethanol; Desderman N, 75.1% ethanol) against feline calicivirus (FCV), the surrogate virus for norovirus, on artificially contaminated hands of healthy volunteers. The ASTM E 1838-02 standard was used. Experiments were controlled with 70% ethanol and 70% propan-1-ol which were previously found to have maximal efficacy against FCV. In the first step, three different organic loads (5% fetal bovine serum, 5% faecal suspension and the tripartite ASTM load) were compared. A significant influence of the type of organic load was found (P<0.001, ANOVA). In the second step, the hand rubs were investigated with a 5% faecal suspension as a challenging organic load. The hand rub based on 95% ethanol was more effective than those based on 70% ethanol (mean log10 reduction factor: 2.17 vs. 1.56; P=0.17) and 70% propan-1-ol (mean RF: 1.63 vs. 0.95; P=0.0003). The hand rub based on 80% ethanol was also more effective than those based on 70% ethanol (mean RF: 1.25 vs. 1.03: P=0.20) and 70% propan-1-ol (mean RF: 1.43 vs. 1.09; P=0.03). The hand rub based on 75.1% ethanol was less effective than those based on 70% ethanol (mean RF: 1.07 vs. 1.27; P=0.47) and 70% propan-1-ol (mean RF: 0.78 vs. 0.97; P=0.35). Based on our data, ethanol has superior efficacy against FCV than propan-1-ol. In addition, a higher ethanol concentration in three commercially available hand rubs was associated with better efficacy against FCV.